Inspection on 15/01/09 for Wyndham House

This inspection was carried out on 15th January 2009.

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

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 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 14/12/06

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 13/03/2009.

Inspecting for better lives Random inspection report Care homes for older people Name: Address: Wyndham House Manor Road North Wootton Kings Lynn Norfolk PE30 3PZ The quality rating for this care home is: The rating was made on: zero star poor service 30/09/2008 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it We give a quality rating following a full assessment of the service We call this a ‘key’ inspection This is a report of a random inspection of this care home A random inspection is a short, focussed inspection Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report Lead inspector: Lella Hudson Date: 1 5 0 1 2 0 0 9 Information about the care home Name of care home: Address: Wyndham House Manor Road North Wootton Kings Lynn Norfolk PE30 3PZ 01553631386 01553631105 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Eaglecrest Care Management Ltd care home 44 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia 0 Over 65 44 Conditions of registration: Admission to additional places can only begin following an improvement in the service level rating for the home Date of last inspection Brief description of the care home 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 en suite The fees for this home range from #380 00 to #597 74 2 1 1 1 2 0 0 8 Care Homes for Older People Page 2 of 12 What we found: We carried out an unannounced visit to the Home on the 15th January 2009 We visited the Home following concerns raised to us about staffing levels and possible medication errors The acting Manager and the Proprietor of the Home were present in the Home throughout our visit The acting Manager said that the usual staffing levels at the Home are for there to be five care staff on duty during the morning, four in the afternoon and two at night time She confirmed that there had been difficulties staffing the Home over the Christmas period due to staff sickness The Manager said that two staff had left since our last visit to the Home She said that she has arranged with the agency for three of their staff to work full time at the Home for the next month All three of these staff have worked at the Home before She said that she has recruited five new staff and that one has already started working at the Home We looked at the rotas and the staff file for the new member of staff These show that the new member of staff has been counted as part of the staffing numbers despite the fact that she is shadowing other staff as her Criminal Records Bureau check has not yet been received although a POVAFirst check has been received We saw from the rotas that there is always a senior member of staff on duty during the day and we also saw that the seniors have received training with regard to the administration of medication We looked at the medication administration records, at the care notes relating to one of the residents and to the staff communication/handover book with regard to a situation regarding medication We also spoke to one of the senior care staff about this At the end of this process the situation was clarified and it was noted that the resident did not receive one dose of medication due to staff error However, the records were not clear and information was recorded in several different places What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 3 of 12 following this report, you can contact them using the details set out on page 2 Care Homes for Older People Page 4 of 12 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection They may not have been looked at during this inspection, as a random inspection is short and focussed The registered person must take the necessary action to comply with these requirements within the timescales set No Standard Regulation Requirement Timescale for action 1 3 17 The service must retain 30/10/2008 records, in accordance with schedule 3 and 4, relating to people living in the home for any period of time This is so that the service can show information relating to individuals health and care needs and how they have been met 2 3 14 1(2) People who use the service 17/07/2008 must have their needs assessed prior to admission so that the home can assure people they have the capacity to meet their needs This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 3 7 15 1 People who use the service 17/07/2008 must be assured that their needs are properly assessed and written into care plans so that their holistic needs can be met This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered Care Homes for Older People Page 5 of 12 4 8 12 1(a) People who use the service 17/07/2008 must be assured their nutritional needs are accurately assessed and met so that their health is safeguarded This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 5 8 13 4 People who use the service must be assured that risks associated with daily living are assessed and action taken to minimise or eliminate risk so that they are safeguarded from harm This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 17/07/2008 6 9 13 Medicines no longer in use for people prescribed them must not be retained at the home timescale 14 days This is so that peoples health and welfare is safeguarded 29/10/2008 7 9 13 Medicines must be given to 29/10/2008 people at the home in line with prescribed instructions at all times This must be demonstrated by the homes record -keeping practices Repeat requirement 08/08/08 This is so that peoples health and welfare is safeguarded Care Homes for Older People Page 6 of 12 8 9 13 Medicines prescribed for 29/10/2008 external application must be safely and securely stored so that people at the home are not at risk of accidental harm Repeat requirement 08/08/08 This is so peoples health and welfare is safeguarded 9 9 12 The non-availability of 29/10/2008 medicines must be avoided at all times Medicines must be promptly obtained so they can be given to people at the home as prescribed Repeat requirement 08/08/08 This is so peoples health and welfare is safeguarded 10 9 13 Medicines must be 29/10/2008 administered to people living at the home by staff who follow safe procedures for their administration at all times Repeat requirement 08/08/08 This is so that peoples health and welfare is safeguarded 11 9 13 Full and accurate records for 29/10/2008 the administration of medicines (including external medicines and those prescribed with variable doses) must be completed by staff at all times Repeat requirement 08/08/08 This is so that peoples health and welfare is safeguarded 12 10 12 The service must ensure that 29/10/2008 peoples privacy and dignity is promoted at all times Care Homes for Older People Page 7 of 12 This is so that peoples health and well being is promoted 13 12 16 The service must ensure that 30/10/2008 people living in the home have the opportunity to exercise choice in relation to all aspects of daily life This is so that peoples health and well being is promoted 14 15 16 The service must ensure that 30/10/2008 people are provided with a nutritious diet that is presented in a way that meets their physical and cognitive abilities This is so that peoples health and well being is promoted 15 22 23 The premises must be 30/10/2008 designed in a way that meets the needs of people with demenia This is so people are supported to orientate independently around the building and to enhance well being 16 26 23 2(d) People who use the service 17/07/2008 must be assured that the home will be kept hygienic, odour free and in a good state of repair and redecoration This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 17 27 18 1(a) People who use the service must be assured that 17/07/2008 Care Homes for Older People Page 8 of 12 suitably qualified competent and experienced staff will be available in sufficient numbers at all times This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 18 30 18 1(c) People must be assured the 17/07/2008 home will provide staff who have been trained to carryout the duties they are expected to perform This requirement made at the last inspection on the 17/07/08 has not been met Enforcement action is now being considered 19 33 24 The service must have systems in place to monitor the quality of the service This is so that the service can identify any shortfalls and make improvements where necessary to promote the health and welfare of people living in the home 30/10/2008 20 37 17 The service must retain records relating to people who live in the home This is to safeguard the health and welfare of people living in the home 30/10/2008 21 37 17 2 The home must keep an 17/07/2008 accurate up to date record of staff on duty each shift to ensure they know who is on duty and that staffing levels can be accurately monitored Care Homes for Older People Page 9 of 12 22 38 37 The service must report all 30/10/2008 serious incidents occuring in the home in accordance with regulation 37 This is so that the handling of serious incidents can be monitored to ensure the protection of people living in the home 23 38 13 The service must have a robust risk management system in place This is so that people living in the home are safeguarded 30/10/2008 Care Homes for Older People Page 10 of 12 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home The registered person had to meet these within 48 hours No Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards The registered person(s) must do this within the timescales we have set No Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 11 of 12 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000 Copies of the National Minimum Standards –Care Homes for Older People can be found at www dh gov uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN Tel: 0870 600 5522 Online ordering from the Stationery Office is also available: www tso co uk/bookshop Helpline: 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 We want people to be able to access this information If you would like a summary in a different format or language please contact our helpline or go to our website Copyright © (2009) Commission for Social Care Inspection (CSCI) This publication 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