Inspection on 24/07/07 for Wyndham House

This inspection was carried out on 24th July 2007.

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 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 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 24th July 2007 10:40 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.V347218.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.V347218.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 Position vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2007 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 en suite. The fees for this home range from £380.00 to £597.74 Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted following an adult protection concern, which subsequently lead to an enquiry into the management and conduct of the service. Due to the nature of the inspection the report focuses on the main care issues and adult protection concern. Readers are encouraged to read the last inspection report for commentary on other aspects of the service. This inspection was held over three days, including one visit that was made on a Sunday, and took approximately 16 hrs to complete. Two regulatory inspectors and the pharmacist inspector were involved in the inspection and examined records relating to residents, staff, and the running of the service. Relatives and residents were spoken with and staff were interviewed. What the service does well: What has improved since the last inspection? What they could do better: The enquiry into the management and conduct of the service has highlighted a number of serious issues that the home must address. The outcome areas that need to be improved are: Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 6 Health and personal care, here there were issues with poor care planning, risk management, record keeping, responding appropriately to health needs and medication management. Complaints and protection, the home has failed to properly record complaints made and failed to maintain systems that protect people who use the service. Staffing, the home has recruited staff who may not be suitable to work in care and has not provided some staff with appropriate training to care for people in this setting. In addition, where issues with staff conduct have occurred the home has not dealt with them in a satisfactory manner and have failed to report these matters to the Commission in accordance with regulation 37. Management, the home does not have a registered manager at this time and evidence suggests that the previous registered manager did not fulfil her duties competently. 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.V347218.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. People who use the service can be assured the home can meet their needs before making a decision to live there. However, based on information provided on the last day of the inspection, people cannot be assured that a person who is trained and qualified to complete that assessment will assess their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the pre-admission process has not changed. The information provided to prospective users of the service had been improved and the home now has a brochure that provides basic information about the facilities and services. 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 Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 9 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 and the home confirms in writing that they are able to meet the assessed needs prior to admission. 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. During the 3rd site visit, the administrator informed the inspector that she had been conducting some of the pre-admission assessments and this was outside of her role. In addition, the administrator is not adequately trained and qualified to complete the assessments and this is of concern, as it may reduce the quality of the assessment. The provider has now addressed this issue and the administrator will be responsible only for tasks stated in her job description. The provider has given the Commission assurances that new residents will not be admitted into the home until the issues identified in this report are resolved and the home is being adequately managed. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. Based on the new evidence from the enquiry thus far, into the management of the service, people cannot be assured that the home is meeting health and care needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspectors examined the files relating to 8 residents and the findings are as follows: Although resident’s files hold a lot of information relating to each individual they are disorganised and this makes it difficult to extract relevant information. Care plans do not provide staff with clear guidance as to how the individual’s needs should be met. They appear as a tick list and in some cases, relevant boxes were not ticked. As stated at the last two inspections, care plans in this Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 11 format are not person-centred and do not reflect the individual needs of the resident. Strong recommendations have been made at the last two inspections and the home has not made the necessary improvements, therefore a requirement is made. See requirements. Daily records completed by care staff do not provide sufficient detail of events and were found to be inaccurate. For instance, one resident was observed in her room, she was clearly distressed and staff were waiting for the GP to visit. The daily records written on the day and the days before the inspection just stated the resident was fine when clearly she was not. When a senior care assistant was questioned about the resident and why she was in her room she replied the lady had been distressed and disturbing other residents so they were keeping her in her room until the GP came at which time they were hoping he would prescribe a ‘calmer’. There was no evidence of the resident being distressed prior to the day and no justification for calling the GP. There were some omissions in other records where it could not be determined what had occurred on some days and no records of events leading up to GP visits or hospital admissions. See requirements. Records of medical intervention are poor and there was a lack of supporting evidence that people’s health needs are being met in a timely manner. For instance, in the records relating to one resident care staff stated that blood was spotted in faeces and urine on the 22/6/07 and again on the 11/7/07 but there was no evidence that the home had contacted the GP or that they had taken any other action. This resident was prescribed antibiotics on the 18/7/07, this indicates that from the 22/6/07 the appropriate medical treatment was not sought. See requirements. Nutrition needs assessments are completed using the malnutrition universal screening tool (although the actual tool was not seen in the files) but were found to be inaccurate. For instance, one resident had lost 10kg in the last 8 months yet her assessment states she at low risk, as do subsequent monthly reviews. There was nothing in the records to indicate that the home has taken any action in response to the weight loss. However, medication records show that a nutritional supplement was prescribed in June 2007 but not given consistently. See requirements. Risk assessments were found to be poorly written and did not cover all risks adequately. The home continues to use a generic tick list format and this does not allow the risk assessments to be individualised. A requirement was made in respect of this at the last inspection. See requirements. Risk assessments were written for the use of bedsides however in one case the use of bedsides was inappropriate and placed a resident at risk of harm on at least one occasion. In this case the family were spoken with and stated they had not been involved in the decision to use the bedsides. See requirements. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 12 During the inspection some observations of staff and residents were made. As mentioned at the last inspection, staff need to be provided with further training and supervision in relation to promoting dignity and respect. One member of staff was heard to speak abruptly to a resident and an incident that occurred in the home not only raises concerns about protection but also the lack of care and respect for people who use the service. In addition, one relative stated that a care assistant spoke to a resident in a way that did not promote dignity and respect; another relative was angry when she reported that a resident was left with food around her mouth. A requirement was made at the last inspection and is repeated here. See requirements. The third site visit conducted some ten days later, on a Sunday, provided more evidence of similar practices in record keeping and staff practice. However, the new acting manager has introduced new documents that will improve care planning, risk assessments and general record keeping. The Commission are yet to assess whether this will achieve better outcomes for residents. An inspection of the medication standard was undertaken simultaneously by the Commission’s pharmacist inspector. Medication records were examined and cross-referenced to resident’s care notes and ‘Occurrence Incident’ records. The findings show that some areas of medicine administration practice places the health and welfare of residents at risk. For instance, when auditing records of medicines of a psychoactive (and potentially sedative) nature prescribed for residents, the inspector found that where these were prescribed for use at the discretion of care staff, there were few associated records to justify their use. In addition, there was a lack of records indicating a psychological deterioration in residents leading to requests of GPs to increase doses of such medicines. The inspector found the quality of medication record-keeping poor. There were omissions in records for both the receipt and administration of medicines. For many medicines there were no means of accounting for medicines to confirm they had been given to residents in line with prescribed instructions. There were some medicines where there were audit discrepancies indicating that they had not been given as prescribed. For one resident there was found to be a significant deficit of a psychoactive medicine and therefore concerns that this may have been given inappropriately. There was also evidence that some medicines had either not been obtained in sufficient time to enable them to be administered as scheduled or could not be located by staff so were not given. For one resident it was of serious concern that when presenting with blood in faeces/urine the resident was not treated until approximately four weeks later. There were also found to be records of other residents regularly refusing medicines and records indicating worsening health where there was no evidence of action taken by the home. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 13 For another resident the inspector identified a series of serious errors by the home where medicines discontinued or reduced by the prescriber had been reinstated further placing the resident’s health and welfare at serious risk. The inspector requested the home instigated an urgent review of prescribed medication for this resident during the inspection. Since the inspection the Commission has requested documentary evidence that members of staff handling and administering medicines have received appropriate training. A separate and detailed report relating to the findings of the inspection has been sent to the provider and is available subject to request. This report includes a total of eight separate requirements. See requirements. Wyndham House DS0000064103.V347218.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 to 15 Quality in this outcome area is adequate. People who use the service can be assured that the home will provide activities, but activity provided is not always based on people’s life experiences and interests. People who use the service can be assured that they will be provided with wholesome food of their choice, but not always based on their personal preferences and experience of dining. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This standard was not fully assessed on this occasion and therefore the reader of the report is referred to the last inspection conducted in June 2007. Further to the information provided during that inspection similar issues relating to staff practice were found during observations on the 3rd site visit of this inspection. However, there were also concerns about staff taking residents from the dining room to the lounge after lunch was completed. One member of Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 15 staff was seen to tell people to go into the lounge giving them very little choice about going anywhere else. In addition this member of staff was heard to talk abruptly to residents giving orders as opposed to options. Most residents were seated in the lounge after lunch and very little was happening for them. One member of staff was sitting with them, but little interaction was taking place. See requirements. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is poor. People who use the service cannot be assured their complaints will be dealt with appropriately and cannot be assured that they are fully protected due to issues with the homes recruitment practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection in June the inspector asked the manager if any complaints had been made since the previous inspection and apart from the one the Commission was already aware of it was reported that no new complaints had been made. During this inspection, there was evidence that complaints had been made but had not been recorded (see standards 7-11) and therefore there was no information relating to the complaints/concerns, any investigation that may have been carried out and subsequent action taken. The home is required to record all complaints and concerns and conduct investigations in accordance with the complaints policy and procedure. In addition, these records should be made available to the Commission on request. See requirements. The home has not taken proper action to ensure that people who use services are protected from harm as they have failed to investigate staff behaviour and follow the correct disciplinary procedures to determine if there needed to be a Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 17 referral to the Protection Of Vulnerable Adults register (POVA) to prevent them working in a care environment in the future. This does not promote the protection of vulnerable people. (See also staffing) See requirements. There were a number of other concerns in relation to the homes ability to protect residents. For instance, the home has employed a number of staff with convictions and while this does not necessarily mean people are at risk of harm, at the time of the visits two of the staff were on suspension and one was dismissed during the inspection due to their conduct while working in the home. This followed a number of complaints relating to the staff members inappropriate behaviour with staff and residents. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate. People who use the service can be assured that the standard of accommodation will be reasonable and constantly improving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This outcome area was not fully inspected on this occasion and readers are referred to the previous inspection conducted in June 2007. However, during this inspection, no new issues with the environment were identified, therefore the quality rating remains the same. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 19 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): 29 and 30 Quality in this outcome area is poor. People who use the service cannot be assured that their needs will be met by a well-trained, competent group of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this inspection, eight staff files were inspected and training records were reviewed. During the inspection it became apparent that there had been issues relating to the conduct of both the manager and staff resulting in the suspension of the manager and three members of staff. One member of staff was suspended during the site visit and another was dismissed. Another two were suspended prior to this inspection but the home had not informed the Commission of the suspensions or the reason why and there was no report available for inspection. The home is required to report to the Commission, all issues of misconduct and this had not happened. See requirements. There were a number of concerns arising in relation to the recruitment of staff with spent criminal convictions. While the Commission accepts that staff may be appointed with convictions the home is expected to carryout robust Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 20 recruitment and risk assessments to assist with the decision making process as to their suitability to work with vulnerable people. See requirements. There were a total of 6 care assistants with spent convictions working in the home at the time of the inspection and there was evidence to suggest that the number had been greater than this in the last 12 months. Some risk assessments had been written but were not considered to be robust, for instance the risk assessment for one employee with previous convictions for assault stated that he must remain ‘calm on duty’ there was evidence in the staff members file that this person had not remained calm at times. The risk assessment had not been updated to take this into account and their suitability to remain working at the home had not been reassessed. In addition, the home should have introduced a plan of increased supervision for these people but whilst this was stated in the risk assessment for the members of staff, it had not happened. For instance, the file for one employee who would need greater levels of supervision showed evidence that one to one supervision had only occurred twice in the 9 months of employment, which does not meet the standard of supervision required in normal situations. See requirements. There was also a concern relating to the provision of training for new staff. In one case a person had been employed as a laundry assistant and provided with a basic induction relating to this role, then transferred to the role of a care assistant, but was not provided with a proper induction to care work. This is of particular concern, as the employee had no previous experience or qualifications in care. In addition, observations of this persons practice raise some concerns. The home has been advised to monitor and assess whether the person is suitable for this area of work. See requirements. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is poor. People who use the service cannot be assured that the home is being managed in a manner that promotes their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned in the summary of this report, this inspection was conducted as a result of an adult protection issue involving the police and social services, which lead to an enquiry into the management and conduct of the service. A visit to the home was made with the police to examine records relating to residents and it became apparent that there were a number of concerns regarding the management of the home as highlighted in this report. For example, a failure to ensure that record keeping was maintained to the Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 22 required standard and that medicines were being administered as prescribed (See St 7-11), a failure to investigate concerns that were raised in relation to staff behaviour and conduct and a failure to report incidents and concerns in accordance with regulation 37 (See St 16-18 & 27-29) The day before this site visit took place the Commission was informed by the registered provider that due to the concerns the registered manager was no longer working at the home and the home would be seeking to employ a replacement as soon as possible. It is of concern that the home is currently without a manager given the number of issues in relation to safeguarding the health and welfare of the people who use the service. However, the provider has assured the Commission that a temporary manager will be brought in the following week. Other standards were not assessed on this occasion and again readers of the report are referred to the previous inspection conducted in June 2007 for information in relation to standards 33,35 and 38. Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X 1 2 Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 24 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(1) Requirement People who use the service must be assured that their needs are properly assessed and written into care plans so that their holistic needs can be met. People who use the service must be assured their nutritional needs are accurately assessed and met so that their health is safeguarded. 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. People who use the service must be assured that they will receive necessary care and medical treatment so that their health and welfare is safeguarded. People who use the service must be assured that privacy and dignity is promoted at all times so that their well being is enhanced. People who use the service must have medicines safely administered by staff who follow DS0000064103.V347218.R01.S.doc Timescale for action 07/09/07 2 OP8 12(1a) 07/09/07 3 OP8 13(4) 07/09/07 4 OP8 12(1b) 07/09/07 5 OP10 12(4a) 07/09/07 6. OP9 13(2), 13(4) 08/08/07 Wyndham House Version 5.2 Page 25 correct procedures by observing safe hygiene and security measures at all times 7. OP9 13(2), 13(4) People who use the service and who need medicines crushed to enable them to be administered must have multidisciplinary team agreement and clear written guidance for staff who adhere to them when giving the medicines People who use the service must have medicines prescribed on a PRN (as required) basis administered only when clinically justified and this can be evidenced by record-keeping practices People who use the service must have action taken by staff to request medical intervention as necessary and appropriate and this can be demonstrated by record-keeping practices People who use the service must have records fully and accurately completed by staff at all times when medicines are administered. People who use the service must have records of medicines received on their behalf into the home fully and accurately recorded at all times People who use the service must have medicines administered by staff in line with prescribed instructions at all times and this can be demonstrated by recordkeeping practices People who use the service must have medicines available for DS0000064103.V347218.R01.S.doc 08/08/07 8. OP9 13(2), 13(4) 08/08/07 9. OP9 13(2) 13(4) 08/08/07 10. OP9 13(2), 13(4) 17(1) schedule 3 13(2), 17(1) schedule 3 13(2), 13(4), 17(1) schedule 3 12(1) 13(2), 08/08/07 11. OP9 08/08/07 12. OP9 08/08/07 13. OP9 08/08/07 Page 26 Wyndham House Version 5.2 13(4) administration as scheduled at all times. The non-availability of medicines must be avoided at all times People who use the service must be provided with choice so that their well-being is enhanced. People who use the service must be assured that complaints will be taken seriously so that their health and wellbeing is safeguarded. People who use the service must be assured that they are protected from harm so that their health and welfare is safeguarded. People who use the service must be assured that the home will maintain records in accordance with the regulations so that their health and welfare is safeguarded. People who use the service must be assured that the home will report to the Commission any incidents or events in accordance with regulation 37, so that they can be properly investigated. People who use the service must be assured that the homes recruitment practice is robust so that their health and welfare is safeguarded. People who use the service must be assured that people employed to work at the home are adequately trained, qualified and experienced in care so that their health and welfare is safeguarded. People who use the service must be assured that the home promotes positive relationships between the proprietor, manager, staff and residents so that people’s health and welfare is safeguarded. DS0000064103.V347218.R01.S.doc 14 OP14 12(2&3) 07/09/07 15 OP16 22(3&8) 07/09/07 16 OP18 13(6) 07/09/07 17 OP37 12(1) 12(2) 12(3) 07/09/07 18 OP37 37 07/09/07 19 OP29 19(5) 07/09/07 20 OP30 18(1) 07/09/07 21 OP32 5 (a,b) 07/09/07 Wyndham House Version 5.2 Page 27 22 OP32 8(1a) 9 People who use the service must be assured that the home is managed by a competent person with an open, positive inclusive approach so that people’s health welfare is safeguarded. 07/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Wyndham House DS0000064103.V347218.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!