Inspection on 27/12/07 for Wyndley Grange Nursing Home

This inspection was carried out on 27th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wyndley Grange Nursing Home 29/11/06

Wyndley Grange Nursing Home 29/12/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Wyndley Grange Nursing home 2 Somerville Road Sutton Coldfield Birmingham West Midlands B73 6JA Lead Inspector Karen Thompson Key Unannounced Inspection 27th December 2007 08:00 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 Wyndley Grange Nursing home DS0000065976.V354589.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. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyndley Grange Nursing home Address 2 Somerville Road Sutton Coldfield Birmingham West Midlands B73 6JA 0121 354 1619 0121 354 1700 nickmurch@hotmail.co.uk www.homecroft-ltd.co.uk Homecroft (Four Oaks) Limited 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) Mrs Marjorie Joan Murch Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That minimum staffing levels are maintained at one nurse and two care assistants throughout the waking day, with one nurse and one care assistant on duty through each night. Care staffing levels are in addition to ancillary support staff. 29th November 2006 Date of last inspection Brief Description of the Service: Wyndley Grange provides nursing care for up to 15 persons. The home is also able to provide care for residents with dementia care needs. The home is not purpose built and is an adaptation of an existing residential property. The home blends in well with the other residential properties within the locality. There is sufficient off road parking for up to seven vehicles at the front of the building. The home has a lounge and dining area, all of which are situated on the ground floor. The bedrooms are of both single and shared status and are situated on the ground and first floor of the building. Both the kitchen and laundry room are on site and the home has a lift and call system. The home has hoists and pressure relieving equipment available to meet the assessed needs of the residents at the home. There are communal toilets located on each floor and assisted bathing facilities are situated on both floors. There is a ramp to the front door to enable access for disabled residents and visitors to the home. The home has a no smoking policy and this is reflected in the Statement of Purpose. The extensive rear garden provides a view of a lake and Sutton Park is within close proximity. The home is situated close to local leisure facilities and bus services run from near by Sutton town centre, with further amenities and shops are a short distance away. The current scale of charges for the home is £475 - £550. The home retains the nursing element, which is paid directly to Wyndley Grange. A Top up Fee of £90 - £150 per week is also payable and these charges are reviewed every April. There are additional charges for chiropody, hairdressing, toiletries and newspapers. For up to date fee information the public are advised to contact the home. A notice is displayed in the reception area to ask the Manager for a copy of Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 5 previous inspection reports for the home, for anyone who may wish to read them. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that needs further development. This inspection was unannounced and conducted over one day commencing on 27 December 2007. This was the first statutory key inspection for 2007/2008 and the manager was present for the duration of the inspection. Information was gathered from a number of sources: a questionnaire was completed prior to the inspection by the manager (AQAA) and on the day of the inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home and conversations took place with managerial and care staff plus visitors and residents. A number of residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to assist with the inspection process. Three residents who live in the home were ‘case tracked’ which involved establishing the individuals’ experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of their lives in the home. Tracking people’s care helps us understand the experience of people who use the service. The quality rating for this service is 2 stars. This means the people using this service experience good quality outcomes. What the service does well: Wyndley Grange provides a homely, clean and comfortable environment in which to live, where staff are friendly and approachable. Residents’ rooms are individualized with personal possessions. Residents’ clothes were nicely laundered. Visiting was flexible and the staff welcome visitors. The staff were able to demonstrate that pre-admission documentation was comprehensive, ensuring that residents are not admitted to the home unless their needs have been further assessed. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 7 Residents are well supported by the care staff to meet their health and welfare needs. Complaints are investigated and actions are taken to resolve complaints. The home maintains a core of staff to provide continuity of care to residents. What has improved since the last inspection? What they could do better: Staff recruitment must include all the required checks such as CRB disclosure, references, health declarations and registeration numbers are checked and made prior to appointment. The menus must include a greater variety and choice to ensure individual preferences are being met. The deployment and timing of meals must be reviewed to ensure that all those who wish to sit at the dining room table for their meals have an opportunity to do so. Training for trained staff must be take place in key areas such as adult protection, food hygiene, dementia care and manual handling. All staff must receive up to date fire training. Carer staff have received training in adult Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 8 protection but this needs to be revisited to ensure they are fully aware of what is required of them to protect and promote the well being of residents. All bedroom should be fitted with a lock that is suitable for resident to use, so if they choice to lock their door they can do so. Formal meeting with residents and or their representatives should be increased to monitor and action the aims and wishes of those living in the home. 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. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 9 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 Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 10 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): 1.2.3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the service or facilities was not comprehensive to enable residents or relatives to make an informed choice about the home. The pre-admission assessment process was consistently comprehensive and therefore residents can be assured that staff at the home are aware of their needs. EVIDENCE: The Service Users Guides were not in residents’ bedrooms. The administrator stated that the Service User Guide was in the process of being revised and had been removed from residents’ rooms. The Service User guide contain information in relation range of fees but did not include information as to the Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 11 range of ‘top-up fees’ and whether the home retained or gave back the nursing element contribution to residents or comments about the home made by residents incorporated into the guide. The Management team stated they were in the process of drawing up a new residential agreement for residents (contract) with a solicitor. Contracts were not looked at during this inspection as these had previously met the standard. A number of residents’ files were inspected to determine the admission process. The pre-admission assessments information obtained by the home met the standard. Individual details were recorded on these pre-admission assessments and there was good evidence of recording residents’ choices, preferences and wishes and of these being implemented when the resident was living in the home. Letters are sent to residents and or their representative to confirm that the home can meet their needs prior to admission. The home does not provide intermediate care, but interim care is available to residents. Interim care is for a short period following discharge usually from hospital and back to ones own home. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of the care plans for the majority of residents was good demonstrating needs were being assessed and that there were strategies in place to meet them. There was evidence of good multidisciplinary working taking place on a regular basis. The arrangements for medication administration were good reducing potential risks to residents. EVIDENCE: The care records of two of the people living at the home were looked at in detail and other records were sampled. Care plans are based on the assessment that is completed before the person moves into the home. The care planning documentation is comprehensive with an array of risk assessments taking place such as skin integrity, bed rails, and nutrition and moving and handling. Following the inspection the inspector was informed that Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 13 the bed rails risk assessment was based on an evidence research based tool. Food and fluids charts were found demonstrating that staff at the home monitor residents well being if concerns have been identified. Daily records were very detailed with details of visitors, how the resident had spent their day, mobility and general care changes. There was evidence that external professionals see residents as required, these included psychiatrists, practice nurses, chiropodists and general practitioners. Monthly weights were recorded and the chart enabled staff to identify any weight loss or gain. The manager has implemented the use of a malnutritionscreening tool and this is assessed monthly. Sore skin risk assessments were completed and care plans gave details about any equipment which was to be used to prevent skin from breaking down. Staff have received training from the Primary Care Trust in relation to skin integrity. Following this course new documentation has been introduced into the home to record, monitor and evaluate wound care. Staff were not however recording when wound dressing had been changed in the appropriate documentation, this is concerning as it could potentially mean that dressings would not be changed at the appropriate time and could therefore delay healing. Following the inspection the Care Manager informed the inspector that the home has reviewed how care planning documentation in relation to wound care is stored and its accessibility so information can be retrieved more easily. Manual handling risk assessments were very comprehensive; detailing what the residents could do for themselves and what they required help with. This included how many staff and any aids were required. This ensures that staff know what equipment to use to safely assist residents meeting their needs. Care plans were evaluated on a monthly basis, but these were not dated and had no signature. Care plans must have a written evaluation, for monitoring care given and identifying any problems occurring. This evaluation had been written in the daily records but this does not assist in the access of the information. Of the three care plans sampled there was no evidence to suggest that residents or their representatives had been involved in drawing up the care plan. The management of medication was reviewed and was well managed, with the exception of boxed medications. Controlled drugs were appropriately stored and recorded. Since the last visit to the home, the home has changed to the Monitored Dosage System (MDS) and audits carried out meet the standard. Identity photographs were available. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 14 Residents were well presented on the day of the visit to the home and wore clothing appropriate to their individual age, culture, gender and personal preferences. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 15 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): 12.13.14.15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice over their daily lives, community contact, and the activities they choose to participate in, which promotes their individuality and independence. The food provided by the home was adequate and a choice was offered but menus need to be devised to ensure residents are aware of the choices available. EVIDENCE: The home does not employ an activities coordinator and this is part of the carer’s role. The home has a planned activities programme for the next twelve months which is to include, mobility exercise, day trips, games, films, quizzes, bingo, a family BBQ and Pimms in the garden. The hairdresser visits once a fortnight. A Christmas party took place in the home on 12th December 2007. Two residents have newspapers delivered to the home and two residents have their own TVs and stereos in the lounge, which they listen to via earphones. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 16 A Catholic Church representative visit every week, visitors come from the United Reform church and a vicar from the Church of England visits regularly enabling residents to continue to follow their religious beliefs. Residents can go out of the home as they are able and the inspector was made aware that one resident had been out for Boxing Day with their family. The home has an open visiting policy but requests if possible that lunch times are avoided in order for residents to enjoy their meals by ensuring their personal comfort. Relatives were observed around the home throughout the visit Residents confirmed there were no restrictions on their activities and that they could go to bed when they wanted and get up when they liked. Visitors confirmed that they are welcomed to the home Staff chatted to during the inspection were able to demonstrate an individual approach to residents care. Residents’ bedrooms were personalized with their own possessions. Staff were observed to assist residents discreetly and sensitively. Lunchtime is difficult due to table space and only seven residents can sit at the table at one time. Other residents remain in their armchair with a small table placed in front of them for their meals. There are not enough facilities due to limitations of space to allow residents to have option of sitting at the dining table. The meal provision for the previous month was examined. The majority of lunch meals consisted of one choice and supper choice was mainly soup and sandwiches. One resident confirmed that the quality of the food was good but there was “very little choice if any” in relation to meals. A review of menus is recommended to ensure that residents get a varied, appealing and nutritious meal that is based on their wishes. Wyndley Grange Nursing home DS0000065976.V354589.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): 16.18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that residents are protected and their concerns listened to and processed in a sensitive and professional manner. EVIDENCE: The complaints procedure is on display in the main reception area and states clearly the procedure to follow should anyone wish to make a complaint. The home had received one complaint since the last inspection at the home. The Care manager was able to demonstrate the concerns were appropriately investigated and the residents well being promoted and protected. The complaint documentation however was not comprehensive and this was discussed during the inspection. CSCI have not received any complaints pertaining to the home. Residents spoken to during the inspection stated that they would go to the management team with concerns and that the management team was approachable. The home had received a number of compliment cards and letters and this suggests satisfaction with the service provided. Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 18 The home has an adult protection policy to ensure that staff have guidelines of what to do should they suspect abuse. Four staff were spoken to about adult protection and gave mixed responses to questions asked in relation to adult protection. Staff have received training in adult protection but further training is required to ensure they fully appreciate the zero tolerance approach to adult protection concerns. Wyndley Grange Nursing home DS0000065976.V354589.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): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Wyndley Grange provides a clean, homely and comfortable environment to live in where residents are relaxed and secure. EVIDENCE: On the day of the visit to the home, it was found to be clean and fresh with no offensive odours, and there was a pleasant atmosphere in the home. The home is in the process of making changes to the environment, which should benefit the residents and enable staff to assist residents to meet their needs more easily. These include extending the building. The owners informed Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 20 the inspector that they have submitted plans to the local planning department, which will extend the home by fourteen bedrooms with communal areas. Windows had been replaced in a number of areas around the home; which will ensure that residents are free from draughts and that their security is maintained. The conservatory is not accessible to residents at the present time as it is being used as an office by the management team. Work has begun on improving the garden area and improving the access for residents. The garden has been partially slabbed to improve access to the garden; however further work is required to allow for ease of access for residents. The management team stated that this would be incorporated into the ongoing improvements. Bathing facilities have been improved since the last inspection. The home currently has one assisted bath on the first floor and two-shower facility for residents on the ground floor. Assisted toilets are available and these have handrails to assist residents with decreased mobility The bedrooms seen were personalised and reflected gender and personal tastes, residents are encouraged to bring in personal items to create a homely environment. The manager informed the inspector that the pictures hung on the stairs walls were on loan from residents who had moved into the home. This allows residents to personalize the communal areas with their own belongings and enjoy their possessions. Only one bedroom door has been fitted with a lock and therefore most residents do not have the choice of locking their door to maintain their privacy. It is required that suitable door locks are installed on all bedroom doors to give residents this choice. Residents’ bedrooms did contain a lockable facility A sluice room on the top floor contained a commode pot disinfector, in order to minimise the risk of cross infection. Gloves and aprons were observed to be available around the home and staff were observed to be wearing appropriate protective clothing in relation to the task they were carrying out. Wyndley Grange Nursing home DS0000065976.V354589.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): 27.28.29.30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appropriate numbers of staff allocated to offer good consistent standards of care to meet the assessed needs of the residents. Recruitment procedures requires improving so that residents welfare is fully safeguarded. Further improvements are required in staff training to ensure that staff have the knowledge and skills to meet the individual and collective needs of the residents. EVIDENCE: There were fourteen residents living in the home at the time of the inspection. Rotas demonstrated five to six carers along with senior staff support is available during the day. There are two night staff on duty and a trained nurse. A cook and maintenance person is employed in addition to the nursing and care staff. Four care staff and one trained nurse is on duty during the morning, two carers and a trained nurse during the evening and one carer and one nurse throughout the night. The manager is supernumery Monday to Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 22 Friday. The home has one part time trained nurse staff vacancies at the time of the visit. Staff files were inspected and were not found to have followed a satisfactory completed recruitment procedure. Staff files of staff recruited to the home since the previous inspection were examined. Two staff files were found not to contain a health declaration form; one of these was completed at the time of the inspection. Two staff members had commenced working at the home with only one reference. Two of the three staff members recruited from overseas did not have a Criminal Records Disclosure carried out. The home has commenced NMC for trained nurses but with the exception of a newly recruited nurse. This check was carried out during the inspection and was satisfactory. A robust recruitment procedure must be carried out to ensure the welfare and safety of residents. Staff files sampled did not always contain photocopies of qualifications; the Care Manager stated that this was sometimes due to delays in the training provider forwarding them onto the home. Copies of certificates were obtained by the home following the inspection and were forwarded to the Commission. The majority of care staff have an NVQ 2 or above or are working towards obtaining one, ensuring that staff have the skills and competences to meet the needs of residents. New staff received an induction-training programme, which gives them the skills and competency to meet the needs of residents. A training matrix has been devised and this demonstrated that the majority of care staff had received training in health and safety, adult protection, dementia care, challenging behaviour, first aid fresher, food hygiene, medication awareness and infection control. This is to be commended however only half the trained nurses working at the home had received any of the above training. The Care Manager is a trained manual handling trainer and this has ensured that staff are updated regularly, ensuring that residents receive care from staff that are competent and skill in moving and handling. Four staff have received fire training in OCT 07 however not all staff have received recent training in fire safety but the home had purchased a training schedule to assist them in ensuring that this mandatory training is completed for all staff in 2008. Wyndley Grange Nursing home DS0000065976.V354589.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): 31.33.35.38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Manager is supported by her staff team and provides clear leadership throughout the home. There are robust systems in place for management of resident’s personal money. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: The Registered Manager has much experience in caring for older people and has previously been the Registered Manager; and continues to be the owner of Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 24 a Residential Home. The Registered Manager is a Registered Nurse and is a Manual Handling trainer, which enables her to train staff at the home. The home is in the process of developing a comprehensive quality assurance system. The last resident/relative meeting was in March 2007. These need to increase to ensure that residents’ views on the home are formally acknowledged. Staff meetings also need to be increased as these last took place in March 2007, these meeting will re-enforce the team working together in meeting residents needs. Questionnaires have been sent out to residents and relatives of which six have been returned. Feedback was mainly positive in relation to care being provided by the home. Copies of Regulation 26 visits carried out by the provider were forwarded to the Commission following the inspection demonstrat6ing that residents and staff needs are being monitored to ensure smooth running of the home. The home can safely keep personal monies on behalf of residents at the home. Three residents monies were reviewed and each resident had an individual transaction record page and individual packets for their money. Receipts were kept alongside the transaction record. Balances were checked and found to be correct. Health and safety maintenance checks have been undertaken on all equipment used within the home including emergency lighting, gas safety certificate, fire alarm systems, lifts, electrical wiring, the nurse call system and hoists. The Environment Officers requirements in relation to tiling in the kitchen and cellar had not been carried out. The need for surfaces that can be cleaned easily is essential to ensure residents are not exposed to any unnecessary risk. A fire risk assessment had been carried out by the home the management team. The home informed the inspector that this had been seen by the fire officer which visited the home. There was evidence that fire drills and fire training have recently been undertaken to ensure that staff have the knowledge to safeguard residents in the event of a fire occurring Wyndley Grange Nursing home DS0000065976.V354589.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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no 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 OP18 Regulation 13(6)18(1 )(c)(i) Requirement Timescale for action 31/03/08 2 OP30 18(1)(c ) 3 OP29 SCh2 @4 19(4) © The Care Manager must by briefing, supervision and training ensure that all staff are familiar with the adult protection policies and procedures All staff must receive mandatory 31/03/08 training on a regular basis in fire, manual handling, food hygiene, adult protection and dementia care to ensure they have the skills and competency to meet residents’ needs. Documents required in relation 21/02/08 to staff recruitment must be obtained prior to commencing working at the home to ensure that resident’s well being is protected and promoted. 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 Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 27 1 OP1 2 3 4 5 6 OP2 OP7 OP15 OP15 OP24 The Service User guide must include list of current ‘top-up’ fees and what happens to the nursing element contribution and comments from residents and be available to residents in their own room and in a format that is suitable to their needs. Current care plan record recording in relation to wound care must be reviewed to ensure that information is easily retrievable Care plan must include where possible the involvement of either the resident or their representative. Menus to be reviewed to ensure that residents have greater choice and variety. The manager must review the dining facilities available; to see whether a staggered mealtime would allow all those who wish to eat at the dining table. Bedrooms require locks to enable residents to lock their door. It is recommended that when all furniture in standard 24 is not provided, this is discussed with the residents and kept on file. (Previous recommendation,) Residents and staff meeting are increased to ensure that concerns and compliments about the running of the home are assessed on a regular basis. Any issues raised at these meeting should be actioned appropriately 7 OP24 8 OP33 Wyndley Grange Nursing home DS0000065976.V354589.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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