Inspection on 29/11/06 for Wyndley Grange Nursing Home

This inspection was carried out on 29th November 2006.

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 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 29/12/05

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 Lisa Evitts Unannounced Inspection 29th November 2006 09:25 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.V319655.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.V319655.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 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.V319655.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 December 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. 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 the first floor. 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, further amenities and shops are a short distance away. The current scale of charges for the home is £525 - £615. A “Top up Fee” of £80 - £100 is also payable and these charges are reviewed every April. There are additional charges for chiropody, hairdressing, toiletries and newspapers. A notice is displayed in the reception area to ask the Manager for a copy of previous inspection reports for the home, for anyone who may wish to read them. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 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 fifteen residents living at the home on the day of the inspection and one was receiving hospital care. Information was gathered from talking with the residents and staff, 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. Prior to the inspection the administrator had completed a pre inspection questionnaire and returned it to CSCI, and this gave some information about the home, staff and residents that was taken into consideration. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. No immediate requirements were made on the day of the visit to the home. 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 are well supported by the care staff to meet their health and welfare needs and are assisted to make choices. Residents/relatives meetings are held and views are sought as to how residents would like to see changes made at the home. Prospective residents/relatives are provided with information about the home to enable them to make an informed decision about whether they would like to live there. Complaints are investigated and actions are taken to resolve complaints promptly. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 6 The home maintains core staff to provide continuity of care to residents. Comments from residents include: “I’m satisfied here” “There is a real family atmosphere” “My family are always made welcome and are given a cup of tea or coffee” “Tea is the best meal, it’s the best meal of the day” “Food is pretty good although there isn’t much variety” “I would speak to Joan if I had a problem, it gets sorted out then, she is very receptive to what I have to say and she takes notice of complaints” “My bedroom is very good, it’s had a spring clean and we moved the furniture around” “Staff are excellent, very good” “Staff are very friendly” “Staff are very prompt” What has improved since the last inspection? What they could do better: Care plans and evaluation of care needs more detail to ensure that staff know the current care needs of the residents. Menus should be available to residents to ensure that they are aware of the choices of meals available to them. Dining facilities need to be reviewed to ensure that all residents have the choice of sitting at a dining table for their meals. Boxed medication administration requires some improvements to ensure that the residents receive their medication as prescribed. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 7 The adult protection policy requires amending to ensure that staff have detailed information to follow in the event of an allegation of abuse. The provider must ensure that regulation 26 visit reports are written and are available to CSCI for review as requested. 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.V319655.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and their representatives with relevant information about the home and this enables them to make a decision as to the suitability of the home. The home has comprehensive pre admission assessments in place to ensure that the home can meet the needs of the resident prior to admission. EVIDENCE: The statement of purpose and service user guide was reviewed as post fieldwork analysis and was found to contain all the relevant information as required by the regulations and this enables residents to make an informed choice about whether to move into the home. Both of these documents are available in large print upon request; this assists readers with visual impairments to access the information. The service users guide is bound and is available in each resident’s bedroom. Two residents did not know of any Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 10 information given about the home (service user guide). The service user guide states what is and is not included in the fees. Four residents files were reviewed and three of these residents had signed contracts of terms and conditions of stay available. The home offers a four week trial period and this gives the resident the opportunity to sample what it would be like to live at the home before deciding if they would like to live there on a permanent basis. The administrator stated that the home was in the process of getting residents contracts rewritten by a solicitor. Two residents were spoken to and one resident said “I’ve forgotten what a contract is, I have to give one months notice, if the costs change they write to my wife” The second resident said “I’ve got a contract, I know how much I pay, if it changed I would expect them to tell me” Detailed pre admission assessments were available on files reviewed and these enable the staff at the home to know that they can meet the assessed needs of the resident prior to admission. One resident did not recall anyone from the home completing an assessment. Letters of confirmation that the home can meet the assessed needs following pre admission assessments are not sent to residents or their representatives and this is required to ensure that prospective residents or their representatives know that the home can meet the assessed needs prior to admission to the home. Since the inspection the administrator has sent a copy of a letter, which is to be sent, and this is satisfactory, this will be further inspected at the next inspection of the home to determine that it has been implemented. During the visit to the home, relatives telephoned and were invited to come and view the home and other relatives came to view the home and were given a brochure. One resident said “My daughter brought me to look around before I came in” and another resident said, “My son looked at the home but I came straight from hospital” Where possible the Manager tries to arrange for the prospective resident to have lunch at the home and completes the pre admission assessment and this gives the prospective resident opportunity to view the home. The home does not offer intermediate care. Comments from residents included: “I’m satisfied here” “There is a real family atmosphere” Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 11 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. Resident’s health and personal care needs are well met by the care staff. Medication was well managed, with the exception of boxed medications, and this ensures residents receive their medication as prescribed. EVIDENCE: Each resident has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the resident to maintain their needs. One file reviewed contained a ‘life history’, which had been compiled by the relatives of the resident. This was very detailed and gave staff information about the life of the resident, which they could discuss and the manager hoped that this could be implemented for other residents at the home. Very detailed risk assessments were in place for a resident who suffered with depression and these had been evaluated regularly, this shows that the illness and potential risks to the resident were being monitored. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 12 Some care plans gave detailed information for staff to follow, for example “can wash hands and face himself” but this was not consistent across all files reviewed and the manager must ensure that all care plans have sufficient details for staff to assist residents to meet their needs. One resident did not have a care plan in place for eating. The resident had been receiving a soft diet but has had had two episodes of choking. A plan of care must be in place to ensure that staff have instructions to follow to minimise the risk of further choking episodes. 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, chiropodist and general practitioner. 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. 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 required. This ensures that staff know what equipment to use to safely assist residents to meet their needs. There was evidence that a resident had developed a sore area of skin but there was no follow up recordings; therefore it was not clear if it was still a problem or if it had resolved. A care plan was in place for a resident who had previously had leg ulcers and the manager stated that these had now healed; however the care plan had not been discontinued. One file had a wound chart for a sore on a hip but no care plan to provide staff with instructions. Staff must ensure that any changes are monitored and the outcomes recorded on a plan of care. Care plans were evaluated on a monthly basis, but this was a date and signature only. 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. 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). Identity photographs were available and a carry forward system was in place to enable audits to be completed and the manager completes these each week. Audits completed on some boxed Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 13 medications were not correct and the manager must review staff’s competence, as residents are not receiving these medications as prescribed. Eye drops were dated on opening to ensure that they were disposed of after 28 days to minimise the risk of infection occurring. 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.V319655.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 & 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, 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 an activities programme, which includes music for health once a month, a fitness trainer once a fortnight, fashion shows, videos/film shows, quizzes singing, skittles and games. External entertainers are booked to visit the home and the hairdresser visits once a fortnight. A Christmas party was arranged for 12th December 2006. 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. The Catholic Church visit every week, visitors come from the United Reform church and a vicar from the Church of England visits and this enables residents to continue to follow their religious beliefs. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 15 Residents can go out of the home as they are able and one resident said, “My son takes me to watch the football”. There was some evidence of residents who had participated in some activities, however this needs further developing as individual records need to demonstrate what residents had chosen to do throughout the day. The home has an open visiting policy however request if possible that mealtimes are avoided in order for residents to enjoy their meals by ensuring their personal comfort. One resident said, “My family are always made welcome and are given a cup of tea or coffee” It was clear from talking to residents that they exercise choice over their lives and one resident said, “I am the last to go to bed and that suits me, I have an arrangement with the night staff”. The lunchtime meal was observed and was unhurried, calm and quiet. Tables were well presented and cold drinks were available. Residents who required these in order to keep clothing clean and maintain their dignity wore padded aprons. Staff were observed to assist residents appropriately and sat down to help residents who required feeding, maintaining their dignity. The manager stated that lunchtime is difficult due to table space and only six residents were sitting at a dining table, with the remaining residents staying in their armchairs. It is required that the manager reviews the dining arrangements to ensure that there are enough facilities for residents to have the choice of sitting at the dining table. Comments from residents about food were varied and included: “There is no variety of food” “Want more bacon and there are no eggs” “Tea is the best meal, it’s the best meal of the day” “Food is pretty good although there isn’t much variety” 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. The home had supplied a two-week menu as part of the pre inspection information, and this showed the choices that residents had been offered over the previous two weeks, although two choices were not always identified at lunchtimes. Residents are asked each day what they would like to eat. Snacks are available throughout the day and these include crisps and biscuits. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 home had received one complaint since the last inspection at the home and the Manager had reviewed the care with the resident and relative in order to resolve the complaint. There was good evidence regarding how the complaint had been resolved and evidence that the situation had continued to be monitored to ensure that the resident was receiving care, as they required. CSCI have not received any complaints pertaining to the home. The home had received a number of compliment cards and letters and this suggests satisfaction with the service provided. One resident spoken to said “I would speak to Joan if I had a problem” and another resident said “I would speak to Joan if I had a problem, It gets sorted out then, she is very receptive to what I have to say and she takes notice of complaints”. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 17 The home has an adult protection policy to ensure that staff have guidelines of what to do should they suspect abuse is occurring, however this requires amending as it makes reference to investigations being carried out and does not mention Health & Social Care as the lead agency. Two staff were spoken to about adult protection and gave satisfactory responses to questions asked, and this knowledge should afford full protection to residents in the event of an allegation of abuse. There have been no adult protection concerns raised at the home. The majority of staff have received training in adult protection, however the manager must ensure that all staff receive training in this area. The home has a Whistle blowing policy, which ensures that staff at the home have the knowledge to protect residents without the fear of reprisals. The missing persons policy has been updated since the last visit to the home and now includes 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.V319655.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 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. The outside of the home had been repainted, facia and guttering had been replaced/cleaned and work was in progress at the time of the inspection on Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 19 replacing the roof. This will ensure that the external building is kept in good state of repair and is of sound construction. Windows had been replaced in the laundry room and there are plans for other windows to be replaced within the maintenance programme, this will ensure that residents are free from draughts and that their security is maintained. Since the last visit to the home the hall, stairs and landing have been redecorated along with five bedrooms, two bedrooms have had new furniture and five new armchairs have been purchased, one room has had a new vanity unit installed and this ensures that residents live in a clean and homely environment. New net curtains have been provided throughout the home to assist in maintaining residents privacy and in creating a homely environment. The conservatory is not accessible to residents at the present time due to work being completed throughout the home. The home currently has one assisted bath and one shower facility for residents, however work was due to commence on the ground floor to create two shower rooms; these will be reviewed at the next inspection of the home. A new bath hoist has been purchased. Assisted toilets are available and these have handrails to assist residents with decreased mobility. The home has four pressure relieving mattresses, two hoists and a range of slings to meet the assessed needs of the residents. One resident was not happy with a pressure-relieving mattress required and stated that “it was too high and lumpy” and the manager was looking for an alternative to resolve the problem. Bedrooms seen were personalised and reflected gender and personal tastes, residents are encouraged to bring in personal items to create a homely environment. Bedroom doors do not have locks and therefore the residents do not have the choice of locking their door to maintain their privacy. It is required that suitable door locks are installed to enable residents the choice. A mechanical commode pot washer/disinfector has been installed, so that staff do not manually clean commodes in order to minimise the risk of cross infection. One resident commented “My bedroom is very good, it’s had a spring clean and we moved the furniture around” Comments from staff included: “I like the changes, its high time the building was done and brightened up” “Changes are really good and definitely for the better” Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 20 One resident commented that they would like a separate room to go into when visitors came and this was also mentioned on a feedback form from a relative. It is recommended that the manager reviews this within the changes currently in place within the home. Wyndley Grange Nursing home DS0000065976.V319655.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. Documentation of recruitment procedures requires improving so that residents are safeguarded. Improvements are required to staff training to ensure that staff have the knowledge and skills to meet the individual and collective needs of the residents. EVIDENCE: 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 Friday. The home maintains a core group of staff and there were no staff vacancies at the time of the visit. The home had not required the use of agency staff and this ensures that residents know who will be assisting them to meet their needs, and that staff know what the residents needs are. The role of senior carer has been introduced and their role is to supervise the shift, ensuring that care, cleanliness and documentation is maintained. Comments from residents included: “Staff are excellent, very good” Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 22 “Staff are very friendly” “Staff are very prompt” The home has 73 of staff who have achieved NVQ Level 2 in care and this ensures that a knowledgeable and skilled workforce is caring for residents. Three staff files were reviewed and were found to contain the majority of information as required. A member of staff who had commenced work at the beginning of the year had not had a Criminal Records Bureau check completed prior to commencing employment, however the home had identified this and a request had been made. A POVA (Protection Of Vulnerable Adults) first check had been sought. All other staff at the home have Criminal Records Bureau checks in place and this assists in safeguarding residents at the home. Two written references were available. One reference had been received and the manager stated she had made further enquiries pertaining to this before deciding to employ the member of staff but there were no written records of calls made. Interview records are not kept and it is recommended that records are kept of interviews and any calls made in order to provide evidence of reasons why a decision has been made to the suitability of the applicant for the job. There was no evidence that Personal Identification Number checks were being completed via the Nursing and Midwifery Council for trained nurses and this is required to ensure that nurses are currently registered and fit to practice, therefore ensuring the safety of residents. Staff have received manual handling training, fire training and are completing health and safety and distance learning courses for infection control. The manager stated that no further training was planned at the present time however the administrator was aware that this is an area that is to be developed and are currently discussing how this is to be achieved. This will be reviewed at the next inspection of the home. A training matrix has been devised in order to identify what training staff have received and what training is required by each individual, however this requires further development as it does not identify when training actually took place. Wyndley Grange Nursing home DS0000065976.V319655.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): 31,32,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Care Manager was supported by her staff team and provides clear leadership throughout the home. There are robust systems in place for the management of resident’s personal money. The home regularly undertakes health and safety checks and this safeguards residents and staff. 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 is a Manual Handling trainer, which enables her to train staff at the home. She has completed a manual handling update, a distance-learning course for medication and has completed the common inductions standards course. This Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 24 shows that the manager is keen to continue to improve her knowledge in order to support and guide staff at the home. A member of staff commented, “Joan is very hands on” Staff and residents meetings have taken place and the minutes of these were available for review. These meetings enable residents, relatives and staff the opportunity to raise concerns or ideas about the home and how it can continue to be improved. A newsletter had been sent out in June to inform everyone about progress of the home and future plans, as the owners had completed their first six months at the home. This ensures that residents and relatives are kept informed about, and are given the opportunity to discuss changes within the home. The home has completed and been awarded the Birmingham Quality Premium for quality assurance. There was some evidence that residents and representatives have completed surveys pertaining to quality of the home. The provider of the home regularly visits the home, however has not produced a monthly written report as is required by the Regulations. The provider must maintain a monthly report as per Regulation 26 and these must be available for inspection. 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. It is recommended that monthly audits of the money are commenced to ensure that balances are correct. The home will also send invoices to relatives if they prefer, this is carried out for two residents at the home. There was evidence on staff files that formal supervision sessions are being undertaken and staff spoken to confirmed that they received supervision. This ensures that any training needs are identified and individual performance is discussed to ensure that the staff have the knowledge and skills to perform competently within their roles. Accident records were reviewed and these were in line with the Data Protection Act. CSCI are informed of accidents/injuries as per Regulation 37. Since the last inspection at the home the manager has introduced an accident log for each resident which enables any trends to be established, action can then be taken to minimise further incidents. Health and safety maintenance checks have been undertaken on all equipment used within the home including emergency lighting, gas safety certificate, fire alarm systems, wheelchairs, lift, electrical wiring, nurse call system, portable appliances and hoists. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 25 Monthly water temperature checks are maintained and were found to be within safe limits to minimise the risk of scalding to residents. The administrator has completed a Fire Safety within Residential Care course; this enables him to train staff at 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.V319655.R01.S.doc Version 5.2 Page 26 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 3 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 27 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. 2. Standard OP4 OP7 Regulation 14(1)(d) 13(4)(c) Requirement Letters of confirmation must be sent to residents following pre admission assessment. Consent for bed rails must be sought and potential hazards must be identified on the risk assessment. (Previous timescale of 13/03/06,not assessed on this occasion) Improvements are required to care including: Wound care plans must be written. Changes must be monitored and recorded. Care plans must be written for specific needs and personal preferences must be recorded. Care plans must be evaluated monthly and a written summary produced. Where possible plans should involve the resident or their representative. (Previous timescale of 31/03/06 Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 28 Timescale for action 24/01/07 31/01/07 3. OP7 15(1)(2) 21/02/07 not met) 4. 5. OP9 OP12 13 (2) 15(1) 16(2)(m) (n) The manager must ensure that staff are administering boxed medications as prescribed. Activity care plans must be written and an individual log of social activities must be recorded. (Previous timescale of 04/10/05 and 31/03/06 not met) The Registered manager must devise a menu, which is changed regularly. (Previous timescale of 03/04/06 not met) The manager must review the dining facilities available. The adult protection policy requires amending. All staff must receive training in protection of vulnerable adults. Bedrooms require suitable door locks. Trained nurses Personal Identification Numbers must be checked via NMC. Regulation 26 visit reports must be written and available for inspection. 15/01/07 21/02/07 6. OP15 16(2)(i) 28/02/07 7. 8. 9. 10. 11. 12. OP15 OP18 OP18 OP24 OP29 OP33 23(2)(g) 13(6) 13(6)18(1 )(c)(i) 12(4)(a) 19 Sch 2 37 31/03/07 29/01/07 31/03/07 31/05/07 19/01/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP24 Good Practice Recommendations It is recommended that the manager review the request for a private room for visitors. It is recommended that when all furniture in standard 24 is not provided, this is discussed with the residents and kept on file. DS0000065976.V319655.R01.S.doc Version 5.2 Page 29 Wyndley Grange Nursing home 3. 4. OP29 OP30 (Previous recommendation, not assessed on this occasion) It is recommended that interview records are kept and evidence of telephone conversations held. It is recommended that the training matrix includes actual dates of training. Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 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. Extracts may not be used or reproduced without the express permission of CSCI Wyndley Grange Nursing home DS0000065976.V319655.R01.S.doc Version 5.2 Page 31 - 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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