Inspection on 29/12/05 for Wyndley Grange Nursing Home

This inspection was carried out on 29th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Wyndley Grange Nursing Home 27/12/07

Wyndley Grange Nursing Home 29/11/06

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 Lisa Evitts Unannounced Inspection 29th December 2005 10:10 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.V276276.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 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 1619 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) Homecroft (Four Oaks) Limited 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.V276276.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That a mechanical commode pot washer/disinfector machine is installed into the home by February 2006. 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. 4th August 2005 Date of last inspection Brief Description of the Service: Wyndley Grange provides nursing care for up to 15 persons aged 65 years of age or more. 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, with a separate sun lounge, 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. There are communal toilets located on each floor and assisted bathing facilities are situated on the first floor. Both the kitchen and laundry room are on site and the home has a lift and call system. 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, further amenities and shops are a short distance away. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one inspector, over one day and was assisted throughout by the Registered Manager and Administrator. There were fourteen residents living at the home on the day of the inspection. Information was gathered from talking with the residents, from observing the care staff perform their duties and from examining care, medication and health and safety records. A partial tour of the building was conducted. This is the second statutory inspection for the 2005-2006 year and it is recommended that this report is read in conjunction with the previous report. One immediate requirement was made at the time of the inspection. The home has very recently been taken over by new owners and it is recognised the inspection was soon after the new owners took over. The Manager has lots of ideas how to improve the home, and it is accepted that it will take time to identify all the areas that need improvements and will take time for the changes to be implemented. The owners have experience in owning and managing a residential home. There are some outstanding requirements from the last inspection that have been inherited by the new owners. What the service does well: What has improved since the last inspection? Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 6 The management of resident’s personal allowances has improved and there is a robust system in place to manage this, to ensure that residents are protected. The manager has ordered new crockery and tabards for the staff to wear while serving food. A new dishwasher and boiler have been ordered for the kitchen, to ensure that there is access to continuous hot water, and allow staff to spend more time with the residents. What they could do better: 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. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 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 Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion but were addressed on the previous inspection. EVIDENCE: One file of a recent admission into the home did not contain any evidence of a pre admission assessment. The resident had been admitted prior to the new owners and manager taking over the home and therefore this will be reviewed again at the next statutory inspection. The Registration certificate for the home was clearly on display in the main reception area of the home. The home does not offer an intermediate care facility. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 9 Resident’s health and personal care needs are well met by the care staff. Improvements are required in respect of care planning to ensure that they include sufficient detail for staff to follow in order to meet the identified needs of the residents. Improvements are required to medication to ensure that residents receive their medication as prescribed. EVIDENCE: Four resident care files were reviewed, two in detail and two to assess specific care plans. Wounds had been photographed, however not all wounds had care plans to describe how to care for the wound and what dressings to apply. Waterlow scores to indicate pressure area care had not been recorded each month. This is required in order to assist in identifying residents who may be at risk of developing pressure areas. Personal preferences, for example likes of bath or shower, were not recorded. Care plans for specific problems had not been written, for example constipation. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 10 Care plans were not evaluated monthly and there was no evidence of resident or family involvement in the process. Two recent admissions into the home did not have manual handling risk assessments in place, therefore there were no instructions for the care staff to follow. One file did not have a consent form for the use of bed safety rails, and consent for use should be obtained to ensure that residents and their representatives are aware of the potential hazards. Staff must be mindful of documenting entries into care files accurately. One care file had recorded a weight of 14.8kgs, which was recorded on another page as 74.8kgs. A blood pressure had been documented as 13/84, which is not a valid recording. There are separate forms for recording visits from visiting healthcare professionals and these assist with ease of monitoring the care provided. There was evidence of G.P visits, opticians and chiropody and evidence that residents have received and attended appointments for various out patient appointments. The daily reports were detailed and included information about how the resident had spent their day, including visitors received, and any care needs identified. The management of medications including controlled drugs was generally good. Exceptions noted were: *The amount of medication administered for variable dosage medication was not always recorded on the Medication Administration Record (MAR)chart. *Not all medications were being signed in upon receipt into the home. *Not all eye drops and insulin had been dated when opened. *Fridge temperature checks had not been recorded. Some medications had excess tablets left over, when cross-referenced against the amount received into the home and the amount administered. Staff must ensure that all medication is administered as prescribed. It is recommended that the manager undertake audits of staff to ensure their competence in medicine management. Copies of the prescriptions were kept alongside the MAR charts and this is in line with good practice recommendations. The manager stated that the home was in the process of setting up a Multi Dosage System through a new providing chemist. This will be inspected at the next statutory inspection of the home. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The food provided by the home was adequate and a choice was offered. Improvements are required, as menus need to be devised to ensure residents are aware of the choices available. EVIDENCE: The lunchtime meal was observed to be unhurried and quiet and residents appeared to be enjoying their meals. Nine of the residents had remained in their easy chairs for lunch with the remainder of residents sitting at the tables. Tables were well presented and the appropriate utensils and serviettes were available. Cold drinks were served with the meals. Food was well presented and colourful, which made it look appealing and appetising. Care staff were observed to be assisting residents to cut up their food as required and assist with feeding, in all areas of the lounge, in an appropriate manner whilst maintaining the dignity of the residents. Comments from residents included: “Staff ask you what you want” “Plenty to eat” “Could ask for something if you were hungry” Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 12 While it was clear that residents had chosen different meals on the day of the inspection and that choices were available, the home does not have a devised menu in place. A written menu, which is changed regularly, needs to be devised to show residents the choices that are available to them. Daily food records are maintained by the cook as evidence of the meal choice taken by each resident. The cook works six days a week and serves breakfast and lunch and prepares the evening meals. The Registered Manager currently cooks meals when the cook is on her rotered day off. A meeting was held at the home, when the new owners and manager took over, to which relatives were also invited. The purpose of this was to introduce themselves to the residents and their representatives, a letter was also sent out informing them of the changes. While there is a range of activities on offer, no further development to the care plans and recording of individual preferences has occurred since the last inspection. A recent admission to the home said,” There is nothing to do, my last home was a bit more active” The manager must ensure that residents have the opportunity to participate in a range of activities and that all individual needs are met. The new manager is keen to implement the necessary changes, which are required, however has only very recently taken over the home. It was pleasing that the administrator had made a video of one of the residents, whose daughter lives in New Zealand and this had been sent to her via email. This ensures that residents are able to keep in contact with their relatives. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints procedure is comprehensive and is accessible to the residents should they need to make a complaint. The home has systems in place to protect residents from abuse. 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 procedure provides contact details for the Commission for Social Care Inspection. The home has a complaints book, however there have been no complaints made since the last inspection, either to the home or directly to CSCI. A range of compliment cards and thank you letters have been received and these are kept alongside the complaint log. One resident said “I’m ok here” and another stated, “I’ve got no problems” One resident said that he had lost some shirts since admission to the home, the manager was already aware of this and staff were checking all wardrobes to ensure that clothing had been placed in the correct wardrobes. The home has an adult protection policy and a whistle blowing policy in place, to ensure that staff have guidelines of what to do should they suspect abuse is occurring. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 14 The missing persons policy was reviewed and requires further improvements to include a statement that CSCI must be informed of any missing residents and that a well person check should be carried out and documented on return. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,24,25 & 26 Wyndley Grange provides a clean, homely and comfortable environment to live in where residents are relaxed and secure. EVIDENCE: On the day of the inspection the home was found to be clean and odour free. Cleaning rotas were in place on the walls in resident’s rooms and these should be removed, as they do not need to be in each room, and it detracts from the homeliness of the room. The home is in the process of obtaining quotes for the fitting of a mechanical commode pot washer/disinfector as per conditions of registration. Sluice rooms require hooks to enable staff to store mops correctly, as they were stored in the buckets. Adequate bathing facilities are available; hoist and bath aids have been serviced. The shower tray requires some attention as the seal has become mouldy and worn. There is an emergency call facility in each bathroom. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 16 In some communal bathrooms there were bars of soap and this may pose a potential risk of cross infection. The laundry room had no soap available. Opened packets of pads were being stored on top of toilets and it is recommended that these are stored in lidded receptacles to prevent the risk of cross infection. Bedrooms seen were personalised with individual belongings to ensure that the environment was as comfortable as possible. A married couple occupy one shared room and this is commendable as allows them to stay together. There was evidence of pressure relieving equipment in place and in use. The conservatory is currently not accessible to residents. Old equipment and wheelchairs are stored in the room and it was very cold. The manager is planning to clear out the room, and order a skip to remove all the old equipment. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29 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 had improved since the last inspection. EVIDENCE: The home has appropriate numbers of staff allocated as per conditions of registration. The manager ensures that one extra carer, above the stated numbers is rostered on duty to assist with the cleaning of the home. Four weeks of off duty planning were taken for review and found adequate staffing levels were maintained. Sickness and absence is clearly defined on the rota. Agency staff had been booked to cover sickness. In addition to the care staff the home also employs a handyman and a cook. There is currently no staff training matrix at the home, and it is recommended that a matrix is devised in order to identify what training the staff have received and what training is required by each individual. The home currently has eight care staff with NVQ Level 2. The most recent staff file was reviewed and this contained all the relevant information. A POVA first check had been received prior to the commencement of employment and there was evidence that a CRB check request had been sent, however not yet returned. The application form was complete and interview notes had been recorded. A health declaration was also on file. There was evidence of past training and evidence of training in moving and Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 18 handling/lifting policy and fire training following commencement of employment at the home. Due to the home being under new ownership, staff will be issued with new contracts. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 & 38 The Registered Manager has previously successfully completed a fit persons interview for another home owned by the company, there are no areas of concern identified. There are robust systems in place for the management of resident’s personal money. 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 a Residential Home. The Registered Manager is a Registered Nurse and has completed courses in nurse prescribing and assessor courses; she is a manual handling trainer and has completed the Registered Managers Award. Health and safety maintenance checks have been undertaken on all equipment used within the home including emergency lighting, gas safety certificate, fire alarm systems, nurse call systems, lift, electrical wiring and hoists. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 20 Monthly water temperature checks are maintained and were found to be within safe limits to prevent scalding to residents. There has been recent staff training for fire and fire drills have also taken place. The accident book was reviewed and only three accidents/injury have been recorded since the last inspection. CSCI are informed as per Regulation 37. There was no evidence of auditing of accidents and it was recommended that a log is kept for ease of monitoring. The Environmental Health Officer had recently been out and inspected the home, four requirements had been made and the Manager had already taken steps to ensure that these were actioned. The Manager must send written confirmation to CSCI, once these actions have been completed. The home currently keeps personal monies on behalf of six residents at the home. 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. It is recommended that monthly audits of the money are commenced to ensure that balances are correct. During the inspection care staff were seen to be using wheelchairs to manoeuvre residents without the use of footplates and this poses a potential risk of injury. An immediate requirement was left that staff must ensure that footplates are in place and in use when transferring residents in wheelchairs. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 22 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) Requirement All prospective residents to the home are required to have a full pre admission assessment completed, prior to being accepted for admission. (Previous timescale of 15/09/06 not met) Manual handling risk assessments need to be amended to include actions to be taken if a resident falls. (Previous timescale of 04/10/05 not met) Manual handling risk assessments must be completed for all residents. Consent for bed rails must be sought and potential hazards must be identified on the risk assessment. Improvements are required to care including: Wound care plans must be written and include type and frequency of dressing change. Care plans must be written for Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 23 Timescale for action 28/02/06 2. OP7 13 (5) 13/03/06 3. OP7 13 (4) (c) 13/03/06 4. OP7 15 (1) (2) 31/03/06 specific needs and personal preferences must be recorded. Care plans must be evaluated monthly. Where possible plans should involve the resident or their representative. Waterlow scores should be recorded monthly. (Previous timescales of 04/10/05 not met) The Registered Person must ensure that medication balances are carried forward to enable a complete medication audit trail of all medication received into the home. (Previous timescales of 31/01/05 & 22/09/05 not met) Improvements are required in respect of management of medication including: The actual amount of medication administered for variable dosage medications must be recorded on the medication charts. All eye drops and insulin vials are to be labelled with the date of opening. (Previous timescales of 22/09/05 not met) Medication fridge temperatures must be recorded at least once a day. Staff must ensure that medications are administered as prescribed. Activity care plans must be written and an individual log of social activities must be recorded. (Previous timescale of 04/10/05 not met) The Registered manager must devise a menu, which is changed DS0000065976.V276276.R01.S.doc 5. OP8 17 (1) (a) (n) 13 (2) 01/03/06 6. OP9 03/03/06 7. OP9 13 (2) 03/03/06 8. 9. 10. OP9 OP9 OP12 13 (2) 13 (2) 15(1) 16(2)(m) (n) 03/03/06 03/03/06 31/03/06 11. OP15 16(2)i Sch3 17 03/04/06 Page 24 Wyndley Grange Nursing home Version 5.1 12. OP18 1a 3m 13 (6) 13. 14. OP19 OP21 13 (4) (a) 23 (2) (d) 15. 16. OP26 OP26 23 (2) (k) 16 (2) (j) 17. OP26 13 (3) 18. OP38 12 (1) (a) 19. OP38 13 (4) (c) (5) regularly. The missing person policy requires amendments to include a statement that CSCI should be informed and a well person check is completed and documented on return. The conservatory must be cleared of all old equipment and furniture. Shower tray requires a replacement seal. (Previous timescale of 04/10/05 not met) Mechanical commode pot washers/disinfectors must be available for staff use. Bars of soap must not be used in sluice rooms and communal toilet areas. Liquid soap and dispensers should be available in all communal areas, sluice and laundry rooms. (Previous timescales of 08/09/05 not met) Hooks must be fitted to the sluice room to ensure that mops are correctly stored to minimise the risk of cross infection. The Manager must forward written confirmation that actions have been completed in respect of the Environmental Health Report. Staff must ensure that footplates are in place and in use when transferring residents in wheelchairs. (The manager received this in the form of an immediate requirement) 17/03/06 31/05/06 24/03/06 28/02/06 28/02/06 15/03/06 15/03/06 29/12/05 Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 25 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. 5. 6. Refer to Standard OP9 OP24 OP26 OP30 OP35 OP35 Good Practice Recommendations It is recommended that the manager undertake medication audits to ensure staff competency. It is recommended that when all furniture in standard 24 is not provided, this is discussed with the residents and kept on file. It is recommended that pads are kept in lidded receptacles in toilet areas. It is recommended that a staff matrix is devised to assist with the monitoring of training requirements. It is recommended that two signatures are obtained when any resident’s financial transactions are made. It is recommended that an accident log is maintained to assist with auditing. Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyndley Grange Nursing home DS0000065976.V276276.R01.S.doc Version 5.1 Page 27 - 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. 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