Inspection on 02/02/06 for Wyndham House

This inspection was carried out on 2nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 14/12/06

Wyndham House 04/05/06

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 Mrs Lella Andrews Unannounced Inspection 10.15a 2 February 2006 and 6 February 2006 nd 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 Wyndham House DS0000064103.V275306.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. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 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 Position Vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (3) of places Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three older people, who are named in the Commission records, who do not have dementia can live at the Care Home. 30th September 2005 Date of last inspection 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.V275306.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and took place between 10.15am and 5.15pm on Thursday 2nd February 2006. Neither the Manager or the Proprietor were at the Home during the Inspection. The Deputy Manager was on duty for the duration of the Inspection and provided information both verbally and in the form of records. The Inspector spoke to three members of staff on an individual basis, inspected a range of records and undertook a tour of the communal areas of the Home. The Manager had provided the requested pre inspection material and the Inspector also took into account an updated action plan (dated 12/01/06) sent to the Commission which detailed the action taken to meet the previous requirements. The Commission is undertaking a joint project with Age Concern in Norfolk which is involving “experts by experience” in the Inspection process. This means that a volunteer from Age Concern, who has been a carer for a relative with dementia, joined the Inspector for part of the Inspection to talk to residents and relatives about their views of the Home. A social worker from Age Concern was also present at this time. An announced visit was also carried out on the 6th February 2006 to inspect some aspects of the environment. The Proprietor and the Manager were present for this visit and feedback was provided to them at this time with regard to the overall inspection findings. The current Proprietor bought the Home eight months ago and appointed a new Manager in July 2005. This Manager left the Home in October 2005 and a new Manager was appointed in November 2005. The Manager has applied to the Commission to be Registered. In general the Proprietor takes his responsibilities seriously and addresses requirements in order to improve the service provided. What the service does well: The residents said that the staff are kind and that they treat them with respect. Relatives are made to feel welcome when they visit. Domestic and catering staff are employed so that the care staff do not have to undertake these tasks on a regular basis. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There is a need to make the care plans more detailed so that they provide guidance for staff about how to meet individual needs. The care plans need to include effective risk assessments. The current staffing levels are not always meeting the needs of the residents and so a full staffing review needs to be carried out so that the appropriate staffing levels can be provided at all times. An Immediate Requirement was given to increase the staffing in the afternoons. The leisure interests of the residents need to be assessed and appropriate activities provided. The Manager needs to make sure that all staff, including night staff and ancillary staff, have attended the necessary training. Better recruitment procedures need to be in place to provide better protection for the residents. There are some areas of hygiene that need to be improved, particularly relating to the laundry room. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 7 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. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 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.V275306.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were measured EVIDENCE: N/A Wyndham House DS0000064103.V275306.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 and 10 The residents have a care plan but these are not detailed enough to provide effective guidance to staff about how to meet individual needs The records are not accurate enough to confirm that all of the residents health care needs are being met In general, the procedures in place for the storage and administration of medication ensure that the residents receive medication appropriately but there is a need for some additional guidance to be provided Residents said that they feel that they are treated with respect EVIDENCE: The Inspector looked at three of the care plans. It is disappointing to see that the previous requirement has not been met with regard to improving the quality of these documents. The action plan stated that the care plans will all have been reviewed by the 31/01/06. From the selection of care plans seen it is clear that this process has not been completed yet as one of the care plans had assessments that had not been updated since August 2005. The other Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 11 care plans had evidence of having been recently updated, however, the quality of these have not improved. The care plans contain assessments relating to moving and handling and pressure area care but do not actually contain detailed guidance to the staff about how to meet identified needs of the residents. For example, one of the residents has a catheter and also has some behaviours which challenge the staff but there are no care plans for these issues. Another resident is identified on the Waterlow assessment (not updated since Feb 05) as having a very high risk of their skin breaking down but there is no care plan in place about how to reduce this risk, nor of meeting the residents needs with regard to continence or mobility. The format of the care plans used is one which is pre-formatted on the computer and therefore the subjects covered within the risk assessments and care plans are predetermined. However, these are not always relevant and the result is that the information is not personalised, that there is a lot of unnecessary information within the care plan and the information required is not there. The requirement to improve the care plans is repeated within this report. The care plans contain a very short social history of the resident and it is recommended that these are more detailed so as to provide staff with a better understanding of the life that the individuals residents have had, including their likes and dislikes, interests and hobbies. The deputy Manager liases with health professionals such as GP, CPN and District Nurses. Senior care staff can undertake these tasks if necessary. Staff said that this has improved the system and that health appointments are followed up more quickly than had previously been the case. However, the care plans are so poor that it is difficult to assess whether the health care needs of the residents are being met. For example, two of the care plans seen were for residents with diabetes and there were no care plans for this. One of the residents had been to accident and emergency as he had hurt his hand. A small break was diagnosed but there was no care plan with regard to this. The medication system in use was inspected. The deputy Manager orders and checks in the medication. The Home uses the monitored dosage system and staff receive training from Boots the chemist. Staff said that once they received formal training they are then observed by more experienced staff whilst administering medication and do not administer alone until they are confident to do so. It is recommended that records are kept of this process. The deputy manager liases with the pharmacist and obtains advice appropriately. Changes have recently been made to the way that the medication is administered in the mornings as it had been recognised that this Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 12 was taking too long and residents were not receiving medication at the appropriate times. Some of the medication was checked and these were seen to be in date and stored appropriately. The record of the temperature of the medication fridge is kept daily and it is recommended that the correct temperature range is recorded on the top of the record sheet so that staff are aware of when the temperature is not within this range and that action needs to be taken. The record of administration was looked at and some gaps were seen. It is required that the medication administration records (MAR) are kept accurately. It is also required that clear written guidance is provided with regard to the administration of PRN (as required) medication. Medication is returned appropriately to the pharmacy but it is recommended that a separate record is kept of these returns. Residents said that the staff are kind and that their privacy is respected. Staff were heard to talk kindly to residents and to explain to them what they were going to do prior to assisting someone. Privacy is reduced for those residents who share bedrooms but screens are provided to assist this process. The previous report required risk assessments to be carried out for residents who share a bedroom and also for all residents with regard to whether they have a lock on their bedroom door. The action plan stated that this has been carried out but the quality of these are poor and so the requirement is repeated in this report. The Inspector was told that there are occasions when staff do not remember to close bedroom or bathroom doors which can compromise the privacy and dignity for the residents. It is required that this situation is addressed. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 13 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 and 13 There are no organised activities and the residents spend the majority of the time sitting in the lounge without stimulation Residents are supported to maintain contact with relatives EVIDENCE: The Home had employed an activities co-ordinator in October 2005 who left the Home in December 2005 and so there are no organised activities available for the residents. The Inspector was told that a new activities co-ordinator will be starting work at the Home shortly and will be working between 2-4pm Monday to Friday. The staff do not have much time to spend with residents on an individual basis due to the staffing levels. Residents said that they get bored as there is nothing for them to do. The Inspector observed situations in the lounge which may have been avoided if the residents were not all sitting in a large group and had more stimulation. It is positive that a new activities co-ordinator will be starting work but there is still a need for a review of activities to be undertaken and plans made to provide additional activities on the days when the co-ordinator will not be Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 14 working. For example, the fourth member of staff on an afternoon shift works from 5pm to 9pm so that there are additional staff to assist at the mealtime and to assist residents to get ready for bed. If this member of staff worked a full afternoon shift there would be an additional member of staff who could be responsible for organising activities each afternoon. It is required that the interests/hobbies of the residents are assessed through discussions with the residents and their families, where appropriate and that plans are in place to provide appropriate activities for the residents. Relatives said that they are always made to feel welcome when they visit the Home. Several relatives were seen in the Home on the day of the Inspection. The layout of the Home does not make it easy for residents to see their relatives in privacy. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 15 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): 18 Improvements need to be made to increase the protection from abuse for the residents EVIDENCE: Staff said that they are aware of the whistleblowing procedure and that they are confident that the management team will deal appropriately with any concerns that they have. Staff said that they are due to attend Protection of Vulnerable Adults training shortly and the Manager confirmed that two sessions have been organised. It is required that all staff attend this training, including night staff and ancillary staff. It is required that the Whistleblowing policy is updated and reflects the name of the Commission rather than the “Inspection Unit” and that it makes clear that the Commission must be notified of all allegations of poor practice, not just when these are substantiated as the policy currently states. There has recently been a situation within the Home which the management team did not deal with appropriately as they did not make the referral to the Adult Protection Unit or notify the Commission of the allegation prior to investigating the situation themselves. This situation has now been dealt with according to correct procedures. During the second visit to the Home there was evidence that the employment of a member of staff was terminated following a founded report of her using rude language to staff and residents. The Commission had not been informed of this situation. Some of the residents have behaviour which challenges the staff and the care plans do not contain enough guidance to ensure that consistent support is Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 16 provided. Staff also need to undertake training to ensure that they provide a good standard of care whilst feeling confident about doing so. Six of the staff recruitment files were seen and two showed evidence that the member of staff had started work without the necessary checks having been obtained, including the Criminal Records Bureau disclosure. An Immediate Requirement was issued to the Proprietor with regard to this. The Inspector was told that the Home does not look after any money for residents and therefore no records are available relating to this. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 17 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, 20, 21 and 26 The environment has been greatly improved in the last eight months although the Proprietor has further plans to ensure that the Home provides a good standard of accommodation throughout. The residents do not have much choice about where they spend their time as there is only one useable lounge Improvements need to be made to improve the standard of hygiene in some areas EVIDENCE: A tour of the communal areas of the Home, including bathrooms was undertaken on the second day of the Inspection. It was noted that the areas of maintenance that had been required to be completed in the previous report have been completed. The doorframes that were in a poor state on the first floor have been improved and new carpet has been fitted in the bedrooms where the carpet was in a poor state of repair. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 18 A more domestic style of lighting has been provided in the bedroom which had previously had a strip light. The Proprietor has carried out a lot of improvements to the environment since he purchased the Home last year. He has a maintenance and redecoration plan for the forthcoming months to ensure that the Home provides a good standard of accommodation throughout. It was noted that the programme of redecoration and refurbishment of the bedrooms is continuing and those bedrooms which have been completed are much improved. The previous report had required that communal toiletries were not used and that the residents have their own toiletries. It was noted that there were toiletries in each of the bathrooms and these did not indicate which residents they belong to and so this requirement is repeated in this report. It was noted that one of the baths on the first floor has a metal edging which the paint is peeling off. It is required that this receives attention. There is a large lounge on the ground floor. Doors have been fitted to one side of the room so that more private areas can be created, however, on both days of the Inspection it was noted that the television was on in both sides of the room but on different stations and the doors were not closed. This causes a lot of noise and confusion as it is not possible to properly hear either television. The requirement to address this situation is repeated in this report. The Home has a large dining room which has very pleasant views over the garden. There is another lounge on the first floor but this room is not used by the residents currently. The room is quite dark as there is not much natural light. Prior to residents using this room it needs to be redecorated and some thought given to appropriate furniture. There was an unpleasant smell in this room on the first day of the Inspection but not the second. The maintenance staff said that there is currently a problem with ventilation which is being addressed. There are bottles of alcohol gel around the Home and the staff carry their own which is a help to reducing infection. However, improvements need to be made in other areas. It was noted that there were no hand towels in the bathrooms. It is required that hand towels are provided in all bathrooms, toilets and ensuites at all times. It was also noted that a used catheter bag had been put into the bin in the bathroom and the bin did not have a lid on, nor was there a bin bag. It is required that catheter bags are disposed of appropriately. The laundry room is sited in an outbuilding next to the Home so that staff have to go outside to access it. It is required that a risk assessment is carried out Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 19 for staff using the laundry room at night. The laundry room has two commercial washing machines and a commercial dryer as well as an incontinence pad macerator. A dedicated laundry assistant is on duty each morning from Monday to Friday. The laundry room was dirty with cracked and missing tiles. The floor was damp in parts. There was dirty washing on the floor in front of the washing machines. The washing baskets were mostly cracked and broken. There was an old rusty free standing radiator which was wobbly and standing next to a plastic washing basket. The Proprietor was asked to remove address this situation during the Inspection and turned the radiator off. It is required that the laundry room is clean and hygienic. Suitable flooring and wall coverings must be provided. The washing baskets must be replaced. The wooden shelves must have suitable covering on them as the paint is peeling. The Manager said that staff carry laundry over the laundry room in their arms which is not acceptable. It is required that a hygienic system is in place for transferring laundry from the Home to the laundry room. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 20 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): 27, 28, 29 and 30 The staffing levels are not being consistently adhered to which means that staff have less time to spend with individual residents whilst providing care Additional training has been provided to the staff and further training is booked which should increase the knowledge of the staff The residents are not protected by the Homes recruitment practices EVIDENCE: The previous Inspection report required the Proprietor to increase the staffing levels in the morning from four to five. This has been actioned by the increase of an additional member of staff on duty from 7am to 11am to assist with residents getting up. However, the Inspector was told that night staff assist some of the residents to get up to assist the morning staff. As the night staff finish work at 7am this means that some residents are getting up very early. It is required that the Manager reviews this situation and ensures that residents are getting up at a time of their choosing. Due to the number of residents it can take over an hour for a member of staff to administer the medication in the morning. This is carried out at a time when the majority of the residents are getting up and so reduces the number of staff available to assist residents. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 21 The staffing rotas show that the usual staffing levels are there to be four members of staff on duty from 7am to 2pm with one additional member of staff on from 7am to 11am. There are then three members of staff on duty from 2pm to 9pm with an additional member of staff on duty from 5pm to 9pm. Two waking night staff are on duty from 9pm to 7am. Using the calculation used to previously work at the necessary staffing ratios there should be 462 care hours provided over the week, not counting night staff. There are currently 399 care hours provided which is a deficit of 63 care hours per week and the rotas actually show that there are occasions when even this level of staffing is not being provided. The Care Home Regulations state that the staffing should be “… appropriate for the health and welfare of service users”. The areas of concern highlighted previously in this report indicate that the staffing levels are not sufficient and it is required that they are increased so as to meet the needs of the residents. It is also required that a full review of staffing is undertaken. The Home provides a high amount of domestic hours and there are domestic members of staff on duty every morning of the week. Between Monday to Friday there is also a member of staff responsible for the laundry. This is positive as it means that staff are not required to undertake these tasks during the morning. The Home currently only has a cook on duty from 8am to 3pm, Monday to Friday. The member of staff who worked in the kitchen during the afternoons has left and has not yet been replaced although the Inspector was told that someone is due to take up this post shortly. Currently one of the care staff undertakes additional hours to work in the kitchen at lunchtime at the weekend. There is no such provision for the afternoons and so one of the care staff is responsible for preparing tea and clearing up afterwards. This reduces the amount of staff on duty to support the residents during this period to two with an additional member of staff coming on duty at 5pm. This is not acceptable and an Immediate Requirement was given to the Proprietor to provide additional staff to work in the kitchen during each afternoon. The Inspector was told that staff have recently received training about moving and handling, and infection control. Training is also arranged for Protection of Vulnerable Adults. Four members of staff have also commenced NVQ training which is a positive step. Induction training has recently been introduced to the Home and all staff are working towards completing this process, not just the new members of staff. The Manager said that the induction standards are in the process of being updated as Skills for Care have produced new standards. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 22 It is required that all staff, including night staff and ancillary staff, have attended mandatory training as appropriate, such as Fire Safety, Health and Safety, Moving and Handling, POVA, Food Hygiene, Infection control and that this training is kept updated. It is also required that each member of staff has a training and development plan. It is also required that those staff who have not done so, attend training about working with older people with dementia. As previously mentioned, six of the staff recruitment files were inspected and two of these show that staff had started work prior to the POVAFirst check or Criminal Records Bureau disclosure having been obtained. There is also no evidence of a police check having been obtained from the country of origin when a member of staff is not from Britain. It is required that all of the necessary information is obtained prior to a member of staff starting work. It is also required that a police check is obtained from another country when a member of staff has been living in another country. The files contain the other necessary proofs of identification and there is evidence that the new Manager has reviewed the files and is in the process of obtaining any outstanding information. It is recommended that written records of interviews are kept. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 23 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): 35, 36 and 38 The Home does not look after residents money Staff would benefit from more consistent, regular supervision Some improvements are needed to promote and protect the health, safety and welfare of service users and staff EVIDENCE: The Inspector was told that the Home does not look after any of the residents money. The only member of staff who has received any formal supervision is the Manager who has received formal supervision from the Operational Manager. The Inspector was told that the Manager will shortly be arranging to carry out Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 24 formal supervision sessions with each member of staff. It is required that all members of staff receive formal supervision six times a year. Staff who are expected to carry out formal supervision must receive training to do this effectively. Staff said that they receive informal support and supervision from the Deputy Manager and Senior care staff. The Inspector was told that the Manager does not spend much time with the residents or staff and so it is the Deputy Manager who provides support on a day to day basis. Standard 38 relating to the health, safety and welfare of the residents was not inspected in full. As previously mentioned in this report the Proprietor has undertaken a lot of work which has improved the health and safety protection for the residents but there are still some areas where improvement is needed. The maintenance member of staff has recently been asked to take on the responsibility for testing the fire alarms and maintaining the necessary records relating to fire safety. It is required that staff take part in fire drills. A fire risk assessment was carried out by an external organisation last year and it is required that the Proprietor informs provides the Commission with a copy of this and advises what recommendations he has carried out with reasons why some have not been actioned. The Manager provided copies of accident reports relating to the residents. It is required that an audit of accidents is carried out on at least a three monthly basis, with particular attention paid to falls. It is required that a risk assessment is carried out for the member of staff who is pregnant to ensure that she, nor the residents, are at risk from her continuing to carry our her regular tasks. Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 25 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 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 2 2 2 X X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 1 X 2 Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 26 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 15 Requirement It is required that the care plans contain detailed guidance for the staff about how to meet the residents needs. The previous timescale of 30/11/05 was not met It is required that effective risk assessments are undertaken and that these are recorded within the care plans The previous timescale of 30/11/05 was not met It is required that the medication administration charts are completed accurately It is required that clear written guidance is provided for PRN medication It is required that bedrooms and bathroom doors are kept shut when in use It is required that an effective risk assessment is undertaken for those residents who share a bedroom The previous timescale of 30/11/05 was not met It is required that risk assessments are undertaken DS0000064103.V275306.R01.S.doc Timescale for action 31/03/06 2 OP7 13 (4c) 31/03/06 3 4 5 6 OP9 OP9 OP10 OP10 13 (2) 13 (2) 12 (4a) 12 (4a) 02/02/06 28/02/06 02/02/06 31/03/06 7 OP10 12 (4a) 31/03/06 Wyndham House Version 5.1 Page 27 8 OP12 16 (2m) 9 10 OP18 OP18 13 (6) 13 (6) 11 OP18 13 (6) 12 13 OP18 OP18 37 13 (6) 14 OP20 12 (4a) 15 OP21 13 (4a) 12 (4a) 16 17 OP26 OP26 16 (2k) 13 (4) 18 OP26 16 (2k) with regard to the provision of locks on the bedroom doors It is required that the leisure interests of the residents are assessed and that appropriate activities are provided It is required that all staff, including night and ancillary staff, attend POVA training It is required that staff receive appropriate training so as to be able to support residents whose behaviour is challenging It is required that the whistleblowing procedure contains the correct name of the Commission and that it clarifies that ALL allegations of misconduct have to be notified to the Commission It is required that notifications of misconduct are made to the Commission It is required that the Adult Protection procedure clarifies the notifications that need to be made and includes the contact numbers for these agencies It is required that arrangements are in place to prevent the television and radio (or two televisions on different stations) being on in the same room It is required that toiletries and razors are not left in the bathrooms and that residents have their own toiletries The previous timescale of 30/09/06 was not met It is required that towels are provided in all bathrooms, toilets and ensuites It is required that a risk assessment is carried out for staff to use the laundry room at night It is required that the laundry DS0000064103.V275306.R01.S.doc 30/04/06 31/05/06 31/05/06 28/02/06 06/02/06 28/02/06 02/02/06 06/02/06 06/02/06 28/02/06 31/03/06 Page 28 Wyndham House Version 5.1 13 (4) room is improved: - that it is clean and hygienic - that it has suitable wall and floor coverings - that the broken washing baskets are replaced - that the shelves have suitable covering It is required that a hygienic system is in place for transferring laundry from the Home to the laundry room It is required that the residents are able to get up and go to bed at a time of their choosing It is required that a review of the staffing is undertaken and that staff are available to meet the residents needs It is required that the staffing levels are increased in the afternoon to provide dedicated kitchen staff to cover for the preparation and clearing up of the tea time meal. An Immediate Requirement was left with regard to this It is required that all staff, including night and ancillary staff, receive training, as appropriate, in mandatory subjects – Fire safety Moving and Handling Food Hygiene First Aid Infection control Health and Safety Dementia It is required that the appropriate checks are carried out for all staff PRIOR to them starting work at the Home An Immediate Requirement was left with regard to this DS0000064103.V275306.R01.S.doc 19 OP26 16 (2k) 28/02/06 20 21 OP27 OP27 12 (4a) 18 (1a) 06/02/06 31/03/06 22 OP27 18 (1a) 28/02/06 23 OP30 18 (1c) 31/05/06 24 OP29 19 (1) 06/02/06 Wyndham House Version 5.1 Page 29 25 OP29 19 (1) 26 OP36 18 (2) 27 OP38 13 (4) 28 29 OP38 OP38 13 (4) 13 (4) It is required that police checks from other countries are sought where appropriate for staff from overseas It is required that formal supervision is provided to the staff six times per year and that all staff providing supervision have had training to do so It is required that a regular audit, at least three monthly, is undertaken of accidents. Particular attention should be paid to the incidence of falls It is required that a risk assessment is carried out for the member of staff who is pregnant It is required that the Proprietor sends a copy of the Fire risk assessment to the Commission with an action plan relating to the recommendations made within the report 31/03/06 31/03/06 28/02/06 20/02/06 31/03/06 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 OP7 Good Practice Recommendations It is recommended that a thorough social history is recorded within the care plans so that staff have a better understanding of the lifestyle of the resident and their likes and dislikes It is recommended that the record of fridge temperatures includes the effective range so that staff are aware if there is a problem It is recommended that a separate record is kept of medication that is put into the pot to be returned to the pharmacy It is recommended that a written record of interviews is kept as part of the recruitment records 2 3 4 OP9 OP9 OP29 Wyndham House DS0000064103.V275306.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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