Inspection on 28/11/07 for Wyndham House

This inspection was carried out on 28th November 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 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 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 28th November 2007 10:30 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.V355748.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.V355748.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 44 Category(ies) of Dementia - over 65 years of age (44) registration, with number of places Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 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.V355748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately 9 hours to complete. During the inspection we completed a tour of the premises, examined records relating to residents and staff, spoke with residents, relatives and staff and made observations of daily routines and interaction between staff and people living in the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that new admissions are dealt with in accordance with the procedures and all new residents are provided with a pre admission assessment. Care plans are still in need of improvement and newly admitted residents did not have all necessary care plans in place to provide guidance for staff as to how their needs should be met. The home also needs to ensure that health assessments, risk assessments and daily records are accurate and reflect people’s current needs. Medication arrangements still do not fully Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 6 safeguard the health and welfare of residents, although some improvement can be seen. The staffing levels are still considered to be too low and in a 28-day period 40 of the daytime shifts fell below the homes own target levels, which is of concern given that these are too low. The practice around medication and the breakfast routine could be linked to poor staffing levels. Improvements are still to be made to the physical environment of the original part of the home and some health and safety issues, such as hazardous products in people’s rooms are still apparent. 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.V355748.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.V355748.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 and 6 Quality in this outcome area is poor, as prospective users of the service cannot be assured the home has an admissions process that includes a pre admission assessment to ensure the home has the capacity to meet the person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures on the admission of new residents. A pre admission assessment is completed and people are invited to visit and view the facilities and services before a decision is made to move into the home. We looked at 4 files relating to people recently admitted to the home. At least two of those people were admitted for short-term respite care, but one person has remained in the home following the respite period. In both these cases there was no proper written pre admission assessment as both were admitted very quickly. For one person there was a fairly detailed Social Services assessment but not for the other. The home could not fully demonstrate that they had gathered sufficient information upon which they could make a Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 9 judgement as to how the needs of the individuals could be met by the staff at the home. See requirements. Wyndham House DS0000064103.V355748.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, as people who use the service cannot yet be assured that their health and personal care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the records relating to six residents and the findings are as follows: Since the last inspection in July 2007 the home has introduced a new care plan format that allows the assessor the flexibility to make them individualised as opposed to the tick list format that was present at the last inspection. This is good and the new care plans contained much more information about how the individual’s needs should be met in a way that is consistent with their previous experiences. However, the home is still in the process of introducing the new care plans and the exercise is not yet completed. It is expected that the home will continue to make good progress in this area. The records relating to newly admitted residents did not contain care plans that covered all their needs and the home must ensure that they train and support staff who are writing care Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 11 plans so that they can fulfil the role competently. The requirement in respect of care planning is repeated here - See requirements. We also looked at daily records completed by care staff and the findings were similar to that of the previous inspection. They do not provide sufficient accurate information relating to daily events. For instance, during the lunch period it was observed that one resident was quite vocal and was swearing at other residents seated at the table. The daily records completed following lunch stated she was fine and ate a good lunch when this was not so. Another resident was observed to have some difficulty with her lunch and ate very little, however it stated in her records that she had eaten well at lunchtime when she had not. When sitting with staff while they were completing records it appeared that the staff delivering the care did not necessarily complete the records and this could be a reason why they are not accurate – see recommendations. Since the last inspection the home has been maintaining good records on medical contacts and the way in which the home responds to peoples health needs has improved and this is good. The nutritional needs assessments are still in need of improvement and the home should consider introducing the Malnutrition Universal Screening Tool (MUST) as a way of assessing people’s nutritional needs. In addition, the home must ensure that care plans are written in order to address people’s dietary requirements. For instance, one resident has experienced a gradual reduction in weight since April 07 and has some difficulty swallowing, the existing screening tool says that the person is at low risk in this area and based on the information available this is not accurate and no action plan has been written to address this need. The findings here are similar to that of the last inspection and the requirement is repeated – see requirements. The home has introduced a new risk assessment format that allows the assessor to produce a person centred risk assessment, which is an improvement on the tick list used previously. However, the general risk assessment was inadequate and those looked at did not cover all risks. In addition, the assessments did not appear to have been completed as intended, which suggests that staff completing the assessments do not understand how to do this effectively and need to be trained. The requirement made at the last inspection is repeated here - See requirements. Observations made during this inspection showed that staff practice in relation to privacy and dignity has improved and staff were seen to approach people in a sensitive manner. This is an improvement since the last inspection and shows that staff have a better understanding of people with cognitive impairments. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 12 A brief inspection of the medication standard was completed by observation of staff administering medicines, examination of the current medication administration charts, some cross-referencing to residents daily records and an audit of some medicines held. The findings show that some aspects of medicine administration practice still places the health and welfare of residents at risk. For instance, a senior care assistant was observed to handle medicines when preparing them for administration. This is considered to be unhygienic. In addition, the medicines trolley was left open and unattended when medicines were being administered at lunchtime and again by a different senior care assistant at teatime. This is considered unsafe as there is a potential risk of unauthorised access to medicines when left unattended – see requirements. Examination of the medication administration charts showed that there were gaps in the record keeping where it could not be established if medicines had been administered or not – see requirements. Two charts for one resident showed the same medicine on both and if the instructions were followed on both charts there is a potential risk of the medicine being administered twice. Signatures appeared on both charts on a total of seven days, which is of concern, as it appears the resident may have been given a double dose on those days. A chart for another resident showed that 100ml’s (20 x 5ml) of Erythromycin was prescribed and the chart showed that 30 x 5ml doses had been given, which would amount to more than had been supplied. This indicates records have been completed by staff when doses have been omitted. When conducting an audit of other medicines there were found to be both deficit and surplus medicines. Therefore, the home cannot demonstrate that medicines have been given in accordance with prescribing instructions. The audit of medication relating to three new admissions all showed some errors and in one case the medicines could not be audited, as the record of receipt and administration did not correspond with the medicines found in the drugs trolley – see requirements. Where residents had been prescribed medicines of a psychoactive nature, there was little evidence in the records that the administration was justified. For instance, one resident was prescribed Lorazepam for agitation; records showed the medicine had been given consistently at night. The person administering the medicine had recorded on the back of the chart ‘given for agitation’ but did not describe what behaviours were displayed and what steps had been taken before using the last resort of administering a sedative medicine. A chart for another resident showed that a further medicine (lansoprazole) prescribed for use ‘when required’ had been given consistently with no record on the back of the chart as to the reason why. The manager stated that this medicine should not be given in this way – see requirements. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 13 The errors found with medication could be attributed to poor staffing levels at times of the day when medicines are being administered. Wyndham House DS0000064103.V355748.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, 13, 14, and 15. Quality in this outcome area is adequate, as people who use the service can be assured that the home is making efforts to provide a service that meets their needs and expectations on this area. However, further improvements need to be made before it can be rated as good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As reported in standards 7-11 improvements are still needed with care plans and this also applies to care plans that address people’s social and emotional needs. Although some improvements have been made and there is more information about people’s life history, further progress needs to be made before it can be said that the home is meeting people’s needs to a good standard. See requirements. The home has increased the number of hours for activities and has two activities coordinators working mornings and afternoons over the week and this is good. There is a plan of group activities that includes art and craftwork, quiz games and some exercise sessions. No activity as such was seen during the inspection, however, we did observe people watching TV, reading and going out into the garden. In the afternoon there was little activity for people and most residents were in the main lounge Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 15 and although there were staff available they did not appear to engage with residents in a meaningful way. The mealtime experience was observed. The home has purchased new crockery, cutlery, tablecloths and napkins and this is good. People were given a choice of clothing protectors and plastic aprons were not seen on all residents as before and Staff were wearing cloth tabards. The overall appearance of dining was better. Most people were seated in the dining area and the experience was much calmer and well organised. Staff were seen to engage with residents and offer choices in terms of drinks and whether people needed some assistance. Those residents needing support to dine were provided with it in a sensitive manner, staff were seen to sit with residents and engage in conversation which is good. Staff spoken with said that they asked residents in the morning what they would like for lunch that day although they stated that sometimes people did not later recall what they had chosen. The home could support memory and recall by displaying pictures of the meals on a menu board or on the table. The home could also use pictorial methods to assist people to make more meaningful choices. See recommendations. The home has made improvements to the timing of meals and the range of choice offered at breakfast. People are now offered a buffet breakfast and a wide range of foods. However, staff spoken with said that while the idea was good it was often unsuccessful due to the limited numbers of staff on duty at that time of the day. Staff assist people up and to the dining room in the mornings and wait for the chef to prepare the breakfast so they can serve it. Staff say they need to continue supporting people with getting up and so cannot stay to supervise and support those seated for breakfast. When they return people have often left their breakfast and moved to another room. (see staffing 27-30 for further details) The meal served on the day looked appetising and most people appeared to enjoy the food and two residents spoken with said the meal was good. At least one resident observed would have benefited from food that she could manage more easily such as finger foods, as she clearly had some difficulty using a knife and fork and did not eat her meal. Staff spoken with said that the resident refused any help offered and when given foods such as sandwiches or sausage rolls she always ate well. See recommendations and requirements in relation to nutritional needs assessments and care planning. The home has appointed a new chef who previously worked at the hospital and therefore his past experience is relevant to this type of establishment. We discussed meal planning with the chef who said he was in the process of developing new menus to make the food offered more suitable for the needs of older people. The home needs to ensure that peoples likes dislikes and Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 16 preferences are taken into account and the information is given to the chef so that he can incorporate this into the menus. In addition, the home needs to ensure the chef is aware of people’s nutritional needs and provide the chef with adequate information and guidance about boosting the nutritional value of food provided for those people assessed as at risk of malnutrition. Guidance is available on the website for the Norfolk and Norwich Hospital in the department of nutrition and dietetics. See recommendations. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 17 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 adequate, as people can be assured that the home will listen to complaints and act in a way that promotes the protection of people who use the service. However, we need to be assured that the home can sustain this approach before the outcome area is rated as good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure, which is contained within the service users guide and publicised at key sites in the home . On this occasion there was no evidence to suggest that complaints were not being recorded and dealt with in accordance with the homes procedures. The new manager has an open and inclusive style of management and during the inspection was seen talking to relatives and visitors to the home. This is good as it allows people to feel able to raise concerns and discuss any issues they may have. One relative spoken with said she felt able to discuss any complaints or concerns with the manager. There have been no further adult protection matters arising since the new manager has been in post. Records show that all staff have received adult protection training this year and further refresher training has been arranged. The manager has dealt with any poor practice/misconduct within the staff group and a number of staff have left the home as a result of this process. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 18 Recruitment practice has improved and the manager says he is committed to employing good quality staff. (see standards 27-30) Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 19 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, 22, 23, 24 and 26 Quality in this outcome area is adequate, as people who use the service can be assured that the home offers accommodation of a reasonable standard. However, improvements are still needed before the home can be rated as good in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was conducted. The home has recently been extended to provide a further eight beds in a new wing of the building with its own lounge dining area and other communal facilities. The bedrooms are all en suite and are of a good size, they are nicely decorated and the furnishings and fittings are of a good standard. An application to increase the registration to 44 beds is being considered by the Commission. Most areas were found to be clean and tidy but some odours could be detected around the home. The home employs 4 domestic staff who work 4hrs per day. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 20 One domestic and the head housekeeper were spoken with, both stated that the job was demanding and it was difficult to complete all tasks fully in the time allocated. However, they would prioritise the tasks to ensure the home was clean and hygienic at all times. There were some concerns that when the new extension is opened there will be further demands on their time. A number of resident’s rooms were entered and most were individualised and contained personal items making them appear more homely. It was of concern that en suites still contained potentially hazardous products such as denture cleaning tablets and this has been raised at previous inspections. It was suggested to the manager that a room checklist is introduced to ensure that once these items are used they are returned to a safe storage place. The manager said they were exploring the possibility of lockable bathroom cabinets that could be used for this purpose. However, in the meantime the home must complete risk assessments and act on the outcome of the assessment in order to protect people from harm - See requirements. The home has introduced some directional signage, however, this could be improved by making the signage clear and putting signage in place to meet individual needs. For instance, one resident was trying to find her way back to her room and while she knew the number and the general direction, she could not remember how to get there. Some directional signage would have helped her memory and recall, which in turn would enable her to return to her room independently - See recommendations. The existing part of the home is in need of some redecoration and it is hoped that now the extension is finished some effort will be put into improving the environment here to make it look more pleasant. See recommendations. Since the last inspection the home has introduced more assistive technology such as pressure mats. This is good as it will promote peoples independence and alert staff to people that may need some support and supervision. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30. Quality in this outcome area is poor, as people cannot be assured the home has sufficient numbers of staff on duty at all times to meet their holistic needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were assessed by observation during the inspection, discussion with care staff and analysis of the staffing roster for the period between 26/10/07 to 25/11/07. At the time of the inspection there were 32 residents accommodated in the home and the home is registered to care for people with dementia. The home has assessed the dependency levels to determine the number of staff needed to meet their needs as 5 between 7am and 2pm, 4 between 2pm and 9pm and 2 between 9pm and 7am. The inspector looked at some of the dependency assessments and did not necessarily agree with the accuracy and the outcome. During the afternoon of the inspection the home was very quiet with little going on for residents the majority of who were seated in the lounge. At this time the staffing levels were reduced to 4 and staff said that at 3pm one of the care staff would have to prepare the teatime meal leaving only 3 care assistants to attend to residents. The home said they had a teatime kitchen assistant who has just commenced maternity leave and they were in the process of appointing another, however, the home should increase the numbers of care staff if one is required to cover teatime preparation. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 22 Additionally, at teatime one of those care assistants was needed to administer medication further reducing the numbers available. Staff also reported that there were insufficient numbers of staff available in the morning and they had difficulty getting people up and down to the dining room where they would serve breakfast. As reported in standards 12-15, staff said they were not able to supervise residents with breakfast as they had to continue helping people up and so residents in the dining room would often leave their breakfast and move to another room. Additionally, staff said that two of the team were required to deal with medication during the early morning shift and start this at 8.30am. This leaves the other three staff to assist the remainder of residents to get up and ready for the day. Staff said they were under significant pressure at this time and could only assist with peoples basic care needs. The staff rosters for a 28-day period were analysed and it was found that 44 of the shifts during the waking day fell below the homes own target staffing levels. This is of concern as the homes staffing numbers already fall below the current best practice guidelines on staffing levels in dementia care services, which states the ratio should be 1 care assistant to every five residents during the waking day. It is also concerning that the home only has two members of staff on duty during the night. The home must ensure that there are sufficient numbers of staff on duty to ensure that resident’s holistic needs are met - See requirements. The files relating to three new staff were inspected and found to be in good order, all files were well organised and contained all the relevant documents and pre employment - this is an improvement. The home has also introduced an induction programme that meets the skills for care requirements – this is an improvement. Since the last inspection, training has been provided in areas such as moving and handling, fire safety, abuse awareness and challenging behaviour. There has been a combination of in house and external training providers, which is good. Further training has also been arranged in dementia education, basic care and health and safety. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36. Quality in this outcome area is adequate, as the home has appointed a new manager who has made some improvements to the management systems in the home. However, further improvements are needed before this outcome area can be rated as good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has appointed a new manager who is a registered nurse and has extensive care and health management experience. At the time of this inspection the manager had been employed for approximately 2 months. During this period the manager has made a number of changes and has dealt with the priority issues identified at previous inspections, such as staffing. There are still some many improvements to be made, however the Commission accepts that the manager has not been in post Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 24 long enough to make significant changes, particularly without the support of a deputy manager. The homes deputy manager, appointed in August 2007 has now left and a new deputy has been appointed to start in December 2007. In October 2007 the home submitted an action plan that stated the improvements to be made and the timescales in which they would be achieved. At the time of this inspection the home had made progress in relation to staff training, supporting staff, mealtimes and the provision of aids and equipment. However, there were still some issues in relation to medication and residents records that still need to be addressed. The homes improvement plan stated that medication issues would be resolved by October 07 and care documentation by 1 December 07 and it cannot be said that the home have met their timescales in this respect. The home has also submitted monthly reports in accordance with regulation 26. These are usually completed by Mr Fanibi, the responsible individual and these could be more robust in view of the poor performance rating of the home. A plan of staff supervision has been introduced, staff now receive one to one supervision sessions bi monthly and staff meetings have commenced on a monthly basis. Staff spoken with confirmed that they have regular meetings but did not always feel that their concerns were listened to. One care assistant said she had still not had a supervision session since she commenced in April. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 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 2 X X 1 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 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 3 17 X 18 3 2 X X 3 3 3 X 2 STAFFING Standard No Score 27 1 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X 3 X 2 Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 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 OP3 Regulation 14(1)(2) Requirement People who use the service must have their needs assessed prior to admission so that the home can assure they have the capacity to meet needs. 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. This is a repeat requirement. People who use the service must be assured their nutritional needs are accurately assessed and met so that their health is safeguarded. This is a repeat requirement. 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 is a repeat requirement. People who use the service must have medicines safely administered by staff who follow correct procedures by observing safe hygiene and security DS0000064103.V355748.R01.S.doc Timescale for action 31/01/08 2. OP7 15(1) 31/01/08 3. OP8 12(1a) 31/01/08 4. OP8 13(4) 31/01/08 5. OP9 13(2), 13(4) 01/01/08 Wyndham House Version 5.2 Page 27 measures at all times. This is a repeat requirement. 6. OP9 13(2), 13(4) 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. This is a repeat requirement. People who use the service must have records fully and accurately completed by staff at all times when medicines are administered. This is a repeat requirement. People who use the service must have records of medicines received on their behalf into the home fully and accurately recorded at all times. This must include medicines for people newly admitted to the home. This is a repeat requirement. 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. This is a repeat requirement. People who use the service must be assured that there will be staff available in sufficient numbers to meet their holistic needs at all times. 01/01/08 7. OP9 13(2), 13(4) 17(1) schedule 3 13(2), 17(1) schedule 3 01/01/08 8. OP9 01/01/08 9. OP9 13(2), 13(4), 17(1) schedule 3 01/01/08 10. OP27 18(1) 01/01/08 Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP15 OP15 OP19 OP19 Good Practice Recommendations It is recommended that the home develop a menu to suit the various mental capacities of people who live in the home so that staff can promote meaningful choices. It is recommended that the home has food available in various forms to suit individual needs, for instance, finger foods. It is recommended that the home continue to develop signage that meets individual needs and promotes their independence. It is recommended that the home continue with a plan of redecoration and refurbishment of the original parts of the home. Wyndham House DS0000064103.V355748.R01.S.doc Version 5.2 Page 29 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.V355748.R01.S.doc Version 5.2 Page 30 - 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. 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