Inspection on 14/12/06 for Wyndham House

This inspection was carried out on 14th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Wyndham House 15/01/09

Wyndham House 21/11/08

Wyndham House 30/09/08

Wyndham House 03/04/08

Wyndham House 28/11/07

Wyndham House 24/07/07

Wyndham House 07/06/07

Wyndham House 04/05/06

Wyndham House 02/02/06

Wyndham House 30/09/05

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

CARE HOMES FOR OLDER PEOPLE Wyndham House Manor Road North Wootton Kings Lynn Norfolk PE30 3PZ Lead Inspector Kim Patience Unannounced Inspection 14th December 2006 11:15 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 Wyndham House DS0000064103.V323847.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. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyndham House Address Manor Road North Wootton Kings Lynn Norfolk PE30 3PZ 01553 631386 01553 631105 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) Eaglecrest Care Management Ltd Vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2006 Brief Description of the Service: Wyndham House is a large detached building in North Wootton, close to the town of Kings Lynn. The Home was originally a Victorian house which has been extensively extended. The Home provides care for up to thirty six older people who have dementia. There are twenty six single rooms and five shared rooms on the ground and first floors. The majority of the bedrooms are ensuite. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection this year. It took approximately 7 hours to complete and the manager was present throughout and was provided with brief feedback during and at the close of the inspection. In order to fully assess the standards, a tour of the premises was completed, staff were interviewed, several residents were spoken with and records relating to staff, residents and the home were inspected. Observations of interaction and activity were made throughout the course of the visit. Since the last inspection there have been seven random inspections, six of those conducted in relation to medication. In the last six months, the management of home has changed. A new operations manager has been appointed and a new manager has been appointed at the home. Both have influenced positive change and as a result significant improvements have been made. What the service does well: • The company director has shown commitment to improving the standard of the service and has responded positively to the requirements of the Commission. Staff were observed to be kind and caring with residents. The home provides homely accommodation that is clean, tidy and pleasantly decorated. • • What has improved since the last inspection? • • • • Eleven of the fourteen outstanding requirements have been met. The pre-admissions procedure is good and new documentation has been introduced. Service users records now include detailed person-centred information. General record keeping is better and easier to extract key information. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 6 • • • • • • • • • The risk assessment process is much better and individual risk assessments are now in place. People’s health care needs are now adequately assessed and nutritional needs assessments are in place. Medication arrangements are now rated as good. On this occasion there were no significant issues in relation to privacy and dignity. The home has appointed two activities coordinators who share a full time post. Information in relation to people’s interest, hobbies and life history has been gathered and is being used to provide person-centred activity. Records of activities and participation have been introduced and are being well maintained. Meals have improved and the menus offer more choice. Residents were satisfied with the food provided. The home now has a system for recording and investigating complaints. They have demonstrated that complaints are now investigated adequately. The adult protection policy and procedure has been updated and now provides accurate information about the relevant agencies. Improvements have been made to the environment such as new carpets, improved safety features, signage and increased choice of communal areas. The culture of care is changing and significant improvements have been made in the area of staff training, support and supervision. The management and administration of the home has changed, producing positive results. • • • • What they could do better: • • The home needs to consider if the new care plan format is adequate for the needs of people with dementia. Staff should be provided with further training in dementia care to enhance their knowledge and understanding. DS0000064103.V323847.R01.S.doc Version 5.2 Page 7 Wyndham House • • • • The home needs to reassess the lunchtime routine to ensure it is organised in a way that meets people’s holistic needs. Risk assessments must be completed for products stored in people’s rooms. The home must increase the staffing levels. The home must introduce a recognisable quality assurance system. 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. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 8 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 Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is adequate, as the home has a clear admissions procedure that includes a pre-admission assessment and provides prospective residents with information about the home to enable them to decide whether the home is suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a policy and procedure for the admission of new residents. Preadmissions assessments relating to two new residents were inspected and found to be satisfactory. All people expressing an interest in the home have an initial basic assessment in order to ascertain if the home can consider the person for admission, based on suitability. Following the initial assessment, people are invited to view the home at any time they wish to. A full pre-admission assessment is completed Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 10 and those inspected contained sufficient detail in order to assess whether the home can meet their needs. Prospective residents are supplied with a copy of the service users guide, statement of purpose, terms and conditions of residence and a copy of the complaints procedure. The home does not have a brochure, but this is in the process of being developed. Full care plans are completed within one week of admission. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10 Quality in this outcome area is adequate, as the home have made significant improvements in this area. However, there are still improvements to be made with care planning and the Commission must see a period of sustained improvement before the home can move to a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files relating to three service users were inspected. Observations were made of those three people engaged in their daily routines and key workers to two residents were interviewed. The home has made significant improvements to the information held on residents and to the record keeping in general. Files contained new Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 12 documentation added to the pre-admissions information, social history, activities of daily living and to care plans. The information in respect of social history and activities of daily living contained good person-centred information from which effective holistic care can be provided. Care plans were an improvement on the previous plans, however, they were pre-printed generic care plans and were not consistent with the personcentred approach taken with other documentation. This is disappointing and the home should consider a more effective care plan system. The care plans inspected, appeared as a tick list of statements with spaces in the format for names to be added. Not all the tick list items applied to each individual, but were still ticked. For instance, one lady who is fully self caring and independently mobile had boxes ticked for use of wheelchair and bedrails, but neither of these items are necessary in her case and there are numerous other examples that can be given. The care plans do not lend themselves to a person-centred approach and the home should consider using a format that allows the freedom to identify the individual needs and to state how care assistants can meet those needs taking into account the strengths and abilities of the individual. A strong recommendation will be made in this respect, as the home has made improvements, however, further improvements must be made. See recommendations. Daily care notes are maintained and are much more organised, again new documents have been introduced here and make it easier to extract the necessary information. Two members of staff were interviewed and stated that the records were helpful in delivering effective care to residents. They found them easy to access and easier to extract relevant up to date information. When discussing the residents and the knowledge staff have about people, it became clear that staff held important information in relation to life experiences and social history, which did not appear in the records. Staff spoken with did not feel they could record such information on the files and the manager should encourage them to do so, as the information will assist the home to meet peoples needs more effectively and to form a better understanding of behaviours and social needs. See recommendations. Risk assessments are much improved and address all risks such as falls and pressure sores, in an individual way. Further improvements could still be made here, such as, ensuring that assessments are written for all risks associated with daily living such as certain behaviours. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 13 Nutritional needs assessments are now in place and weights are being monitored. There is evidence that where a risk of poor nutrition has been identified, action has been taken and a referral has been made to the GP. The home is planning to introduce the ‘Malnutrition Universal Screening Tool’ in January 2007, this will allow further improvement and therefore, meeting needs more effectively. The home maintains good records in respect of people’s health and medical contacts. Resident’s files showed that where a medical need had arisen, the appropriate health professional had been contacted. Since the last inspection in April 2006, the home has been subject to a number of inspections by the specialist Pharmacist inspector, the first took place on the 03.05.06 and serious concerns were identified with the safe administration of medicines. A follow up visit on the 26.06.06 showed that the home had not complied with the requirements made at the first inspection and medication arrangements were still unsafe and therefore people were being placed at risk of harm. Due to the level of concern and non-compliance a statutory notice was issued on the 06.07.06. Subsequently, three random inspections have been completed on the 08.08.06; 21.09.06 and the last on the 02.11.06 showed that the home had made significant improvement and medication arrangements and practice could be rated as good. There were no apparent significant issues in respect of privacy and dignity. However, the home should be mindful of the storage of personal items such as incontinence pads and place them out of view. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 14 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): 12,14,15 Quality in this outcome area is adequate, as the home has made significant improvements here. However, further improvements are needed to ensure that mealtime is a pleasant meaningful experience and that staff respond flexibly to peoples changing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been improvement in this area since the last inspection. Resident’s records included personal information about people’s life history, interests and hobbies. Although it is not clear if the home has understood how this information can be used to provide activity that is meaningful to the individual. However, it is a good start and the home should use the information to design individual plans of activity based on the person’s life experiences. For example, one resident worked for 36 years in the same job but the field of employment was not Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 15 noted and this could have provided information about an activity she may enjoy. The home has employed two members of staff who are dedicated to this task and have drawn up a programme of group activity, which was on display around the home. In addition, records of activity are maintained for each individual and state what they have participated in. Some of this information shows that the home is providing a mix of group and one-to-one activity. One resident spoken with talked about the art and craftwork she has completed for Christmas and how much she enjoyed the experience. Other resident’s artwork was on display around the home. In the communal areas after lunch, people were observed doing crosswords, knitting and reading the paper. There were clear signs of well-being with many of the residents and this is good. One member of staff interviewed said that staff would benefit from some training in the provision of activity for people with dementia. Clearly, any training will support staff to fulfil their role more effectively, however, it is important that staff understand person-centred care and how activity is incorporated into normal daily life. It is essential to have knowledge of each individual’s life experiences in order to be able to step into their reality to achieve this. Further or enhanced training in caring for people with dementia would be more beneficial. See recommendations. The mealtime experience was observed, menus were inspected and people were asked about the quality of the food. The home has a full time cook who works 7-2 pm seven days per week. A kitchen assistant is employed during the same hours to support the cook. Since the last inspection a kitchen assistant has been employed to work between 16.00-18.00 to serve tea, allowing care assistants to focus on care tasks. This is an improvement. Menus are designed by the cooks and information provided by the manager about peoples likes, dislikes and dietary needs. New winter menus have been introduced and the home will continue to introduce seasonal changes throughout the year. The meals are sampled by the manager and the administrator daily and feedback on the quality of the food is provided. In addition, cooks rely on staff to provide feedback on whether the residents have enjoyed the meal. The dining room was nicely laid out for lunch with tablecloths, napkins and menus on the table. Most residents were seated in the dining room and lunch was being served at approximately 12.30pm. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 16 There were two main meal choices; casserole with vegetables or quiche with baked beans and sautéed potatoes, people had been asked what they would like earlier in the day. The food was well presented and looked appetising. The home could make further improvement here by considering the organisation of serving meals. For instance, those who chose casserole were served their food first, despite the fact that others, who had chosen the second option, seated at the same table, did not have their meal. This caused conflict on some tables, as people could not understand why they did not have their meal at the same time and arguments ensued. One resident was shouting for his meal before any food was served yet his meal was not provided until later. Other residents were becoming agitated by his behaviour, which could have been prevented by serving his meal first. See recommendations. The dining room was adequately staffed during lunch and this is an improvement. Staff were available to assist residents where necessary and two residents needed full assistance to eat their meals. In one case the care assistant was observed to sit discretely at the table to provide the assistance but in the other case the care assistant stood behind the resident and this is not good practice. When discussed with the manager, she stated that staff do normally sit with residents but for some reason did not do so on this occasion. See recommendations. There were also a number of residents that would have clearly benefited from some prompting and modelling as they found it difficult to use the cutlery. Staff were present in sufficient numbers, but needed to be more alert to the fact that people’s needs vary on a daily basis and they should respond accordingly. The food served is also a contributory factor, for instance one lady could not manage to eat her baked beans with the cutlery and therefore was using her fingers, another also had some difficulty with the same food and most of it ended up in her lap. As a result, she spent some time trying to clean her trousers, as she obviously took pride in her presentation and found it distressing to have soiled clothing. Nutritional needs assessments are completed as stated in standards 7-11, however, the home needs to consider the practical elements of nutrition such as, the ability to use cutlery and manage certain types of food, as well as the clinical aspects. See recommendations. Various drinks were served at lunchtime and staff were offering choices and alternatives, this is good practice. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 17 Several residents were spoken with during and after lunch, all appeared to enjoy the food. One resident stated that the food was always good, but there was always a long delay between the main meal and pudding. Observations confirmed this, but as mentioned earlier, it was due to the order in which meals were served. People were restless between servings and started to move away from the tables. Following lunch one resident was assisting to clear the tables, clearly an activity she enjoyed. Wyndham House DS0000064103.V323847.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): 16,18 Quality in this outcome area is good, as the home has made improvements here and now have robust systems in place that serve to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure that is now well publicised. A copy of the complaints procedure is included in the pre-admission information and posted prominently in the reception area of the home. People are encouraged to make comments or complaints and as such, a tray has been placed in the entrance so people can do this easily and anonymously if they wish. At the last inspection, issues arose with the way in which the home record and investigate complaints. Since then the home has a complaints log and has produced satisfactory investigations of outstanding complaints. In addition, the Commission has received 6 anonymous complaints that were passed to the home. The manager and operations manager have provided full investigation reports in response to the complaints and these were found to be satisfactory. This is an improvement. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 19 The home has not directly received any other complaints since the last inspection. The manager is much more visible and now occupies an office downstairs, she now has regular contact with visitors to the home and is available to discuss any issues as they arise. In relation to adult protection, the home now has a satisfactory policy and procedure in place. Staff have been provided with some training and those spoken with were aware of adult protection and the procedure for dealing with issues that may arise. Wyndham House DS0000064103.V323847.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): 19, 26 Quality in this outcome area is adequate, as the home have and continue to make good progress in this area. However, there are still some minor issues to address in relation to health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was completed. All areas were found to be clean, tidy and relatively odour free. Improvements have been made to make the premises safer for residents such as locks placed on cupboards that could place people at risk if accessed. Further improvements are needed in terms of safety and the home must Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 21 assess the risk presented by products such as denture cleaning tablets stored in people’s rooms. See requirements. The home now has a full risk assessment for the premises, which was completed by an independent assessor. The carpet has been replaced on the first floor and has improved safety and the appearance. Signage has been improved and bedrooms now have a photo and the name of the resident to aid orientation and recall. The home should continue to improve signage, as people’s needs change. See recommendations. Some changes have been made to the communal areas to provide more choice of where people can sit. Some chairs have been placed near the window in the dining area, overlooking the garden. Several people were seated here and appeared to enjoy the privacy. Others were seated in the reception area and again clearly enjoyed seeing people pass by and stopping for a chat. Some resident’s rooms were entered and found to be clean and tidy. The rooms were personalised with photos and other personal items. The new manager has encouraged relatives to bring in items that people are familiar with to make rooms more homely. For instance one relative was previously told she could not change the soft furnishings in her mothers room to those her mother had at home. She is now encouraged to do so, as this will help her mother to settle in her surroundings with things that are familiar and comforting to her. Further improvements are to be made to the environment and are built into the improvement plan submitted by the home. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is poor, even though the home has made significant overall improvement in this area. Improvement is still needed to increase the number of staff employed on each shift and to increase the team’s knowledge of people with dementia. These issues will need to be resolved before the home can be considered as adequate in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two members of staff were interviewed, staff files were inspected, training records were assessed and copies of the staff rosters for the last four weeks were provided by the manager. At the time of inspection the home was accommodating 35 residents. The homes target staffing levels are 5 care assistants in the morning, 4 in the afternoon and 2 during the night. An analysis of the rotas taken showed that the staffing levels have regularly fallen below the homes own targets and this is not acceptable when the levels are so low. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 23 Although there was no evidence, on the day of inspection, that people’s needs were not being met to a satisfactory level, the current staffing levels raise concerns about how well people’s needs can be met, given that most residents accommodated have a moderate to high level of dementia. It is expected that homes providing this type of service will work to targets of one care assistant to five residents, therefore this would indicate that the staffing in this home should be increased, particularly at peak times such as early in the morning and in the evening when people need assistance to go to bed. Observations of the lunchtime routine showed that although there appeared to be sufficient numbers of staff on duty in the dining room, there were no other staff available in the rest of the home. This could call into question the choices available to people about where they wish to eat their meals. For instance if people decided to eat in their room or in the lounge it is unlikely they would be able to do so, due to the limited staff available to facilitate. In addition, the low numbers of staff in the afternoon could also limit people’s choices in respect of bedtimes. A requirement is made for the home to review the staffing levels and make necessary adjustments based on the needs of individuals. See requirements. At the last inspection, there was a concern about the number of agency staff used, the home has now appointed sufficient bank staff to cover at times when permanent staff are on leave. This is a positive move forward. Since the appointment of the new manager there has been a change in the culture of care in the home and staff appeared to have a greater awareness of peoples needs. However, some observations made suggested that staff need further training in dementia care, perhaps at an advanced level. For instance, one resident who was fairly vocal, was left sitting in the dining room waiting to be taken into the lounge. Staff were busy assisting other residents and were walking to and fro. The resident called out to staff as they went by and was not acknowledged at all, the resident showed frustration at being ignored and became agitated. Eventually a member of staff came to her attention and the resident asked to go home, the member of staff promptly told her she was at home, which she did not believe and this caused her some distress. Further training would provide staff with a greater understanding of the experience of a person with dementia and the importance of being able to step into the person’s reality in order to meet their needs effectively. See requirements. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 24 The provision of training has greatly improved and the home is investing in its staff and this will inevitably raise the standard of care. The manager was able to provide a plan of training that has taken place and is planned for the coming months. The plan includes training in fire safety, Moving and handling, COSHH, Food hygiene, falls training, adult protection, medication and care planning. In addition, some specialist training is being provided in challenging behaviour and reflective practice. Furthermore, the home has 13 members of staff who have either completed or are in the process of completing an NVQ2 and 5 members of staff who are working towards an NVQ3. Three other care assistants are waiting to be registered. This is good and shows the homes commitment to raising the knowledge and skills of the workforce. At the last inspection, issues were identified with the homes recruitment practice. This has improved and the two new staff files inspected were found to be in order. The homes administrator has devised a file checklist to ensure that all the necessary documentation is contained within the files and that preemployment checks are completed prior to the commencement of new staff. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 25 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): 31,33,35,36 Quality in this outcome area is adequate, as the home has made significant improvements in the area of management and administration. However, the manager is yet to complete the registration process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager employed at that time has been dismissed. The home was not functioning to an acceptable standard and the manager had not managed to make the necessary improvements. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 26 The home has employed another manager who is a registered nurse and has substantial experience in the field of nursing and social care. She has completed ongoing training in order to retain her registration as a nurse and has completed advanced training in the care of older people with mental health issues. The home has submitted an application for registration that is currently being processed. Staff interviewed, spoke positively of the new manager, stating that she has an inclusive style of management and is focussed on building a team that works together in order to provide best outcomes for residents. Staff also spoke of feeling valued by the organisation through the consultation process and the training offered. This is an improvement on the previous findings and is a credit to the management. There have been significant improvements to the outcomes for residents since the appointment of the new manager and she has demonstrated competence in her role so far. In addition, since the last inspection, the operations manager employed at that time has been dismissed and another has been appointed. Again, the operation’s manager has influenced improvement here and has been of good support to the manager. Regulation 26 reports have been provided monthly and recently the operations manager has conducted a quality audit of the service and provided the Commission with a report. This home now appears to have a sound management structure that performs well and is committed to driving improvements in the standard of the service. This can only be beneficial to residents and the Commission is pleased with the progress made here. The home is yet to formalise a recognisable quality assurance system that includes consultation with all the major stakeholders. However, training in this subject was scheduled for managers in December, but has been postponed until January 2007. The home must establish and introduce a quality assurance system and produce an annual report on the findings that is provided to all stakeholders and the Commission. See requirements. It is suggested at his stage, that an effective way of disseminating this information to stakeholders is via a newsletter that can be used as a multi purpose document to inform stakeholders of items such as, staff Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 27 achievements, events, general news and quality issues. See recommendations. The home does not hold any money for residents and therefore does not get involved in the area of personal finances. A programme of staff supervision has been implemented and staff are now provided with monthly supervision that is documented and kept on the staff members file. Staff spoken with found these sessions beneficial, however, stated that the manager has an open door policy and was available at any time they needed to discuss issues of a personal or professional nature. Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 28 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 X X 3 X X X 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 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X X Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 13 (4c) Requirement It is required that effective risk assessments are undertaken and that these are recorded within the care plans. This applies specifically to products stored in people’s rooms. Timescale for action 28/02/07 2. OP27 18 (1a) It is required that the home has 28/02/07 adequate numbers of staff on duty at all times. The home must review and increase staffing levels according to the needs of the residents. This is repeated for the third time. 28/02/07 It is required that the home establishes and maintains a system for monitoring quality. The system must include consultation with all stakeholders and an annual report on the quality review must be produced and supplied to stakeholders and the Commission. 3. OP33 OP10 24(1)(2) Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 30 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. 2. 3. Refer to Standard OP7 OP7 OP15 Good Practice Recommendations It is recommended that the home consider changing the care plan format to one that allows the flexibility to assess and record people’s needs in a person-centred way. It is recommended that the home encourages staff to record new information and changes in needs in the residents care records. It is recommended that the home consider the organisation of mealtime in order to meet peoples needs more effectively. It is recommended that the manager remind staff of the importance of discretion when assisting people with their meals. It is recommended that the home assess the practical elements of nutritional needs in order to meet them more effectively. It is recommended that the home continue to make improvements to signage. It is recommended that the home consider devising a newsletter as a vehicle to distribute key information to stakeholders. 4. 5. 6. 7 OP15 OP15 OP19 OP33 Wyndham House DS0000064103.V323847.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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