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Inspection on 06/06/06 for Wyndthorpe Hall & Court

Also see our care home review for Wyndthorpe Hall & Court for more information

This inspection was carried out on 6th June 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users particularly enjoyed the holidays held recently, with a short holiday for two groups of people in adapted caravans in Blackpool. There have also been a number of outings including one to the coast for the day, and a theatre trip that were enjoyed. There are weekly film shows that are very popular, and some of the memorabilia activities are also enjoyed. Some service users want more activities, claiming that there is not enough to do. Some people felt very well cared for, and had a lot of praise for the staff, both caring and cleaning, and enjoyed the meals.

What has improved since the last inspection?

What the care home could do better:

The feedback from service users and relatives to CSCI was very mixed with some people being very satisfied and others not so satisfied. The home would benefit by obtaining views about the home in order to make improvements to the service it offers. There were some concerns around the different needs of service users with and without dementia and how it was being managed. Care plans were much improved but were not all completed. Some Medication practices were found to be poor and must be addressed quickly for the safety of service users. The allocation of staff should be reviewed, prior to any change in registration category, as there are times when the care staff are not always meeting service users needs. Information provided to people living at the home or coming into the home should be more up to date and accurate. Activities provided are good, but there are not enough and not enough time spent with individuals. The quality of meals was thought to be good, but could be improved by promoting more choice, such as not mashed potato every day, or sandwiches, and the inclusion of more fruit and vegetables. The environment has had some improvements, but there are some areas that require complete refurbishment such as bathrooms, and some bedrooms. Staff development is not consistent, with supervisions and training falling behind schedule. The area of most concern was the standard of the laundry service, and it would benefit the home for service users to have some facilities that they could use themselves or with assistance.

CARE HOMES FOR OLDER PEOPLE Wyndthorpe Hall & Court Wyndthorpe Hall High Street Dunsville Doncaster DN7 4DB Lead Inspector Ms Stephanie Kenning Key Unannounced Inspection 6th June 2006 10:00 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 Wyndthorpe Hall & Court DS0000048425.V290517.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. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyndthorpe Hall & Court Address Wyndthorpe Hall High Street Dunsville Doncaster DN7 4DB 01302 884650 01302 890032 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) Four Seasons Homes (No 6) Limited (A wholly owned subsidiary of Four Seasons Healthcare) Mrs Susan Howden Care Home 44 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (20) of places Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A service user with a mental disorder, named on variation dated 3rd May 2005, may reside at the home. One specific service user under the age of 65, named on variation dated 20th February 2006 may reside at the home. 20th December 2005 Date of last inspection Brief Description of the Service: Wyndthorpe Hall and Court are one registered service providing two types of service in separate parts of the building. The old Hall is a converted building for up to 20 older people who do not require nursing care. The Court is an extension for up to 24 older people who have dementia, but who do not require nursing care. It is set in large gardens at the edge of the village of Dunsville near Doncaster. Another home, also owned by Four Seasons, is located in the grounds of the home, and the regional offices of the company are based in Wyndthorpe Hall. Both parts of the building are on two floors connected by shaft passenger lifts, and staircases, and are connected to each other on the ground floor with key pad locks on the door. There are a number of communal areas in each part of the building, all on the ground floor, and some have access to the gardens. Most of the bedrooms are single and some have an en-suite toilet and wash basin. There are a number of bathing facilities and toilets around the home, that are dated and are limited in their facilities for assisting people with disabilities. The company have proposed to apply to change the registration so that all the people residing at the home will have dementia, and also propose to upgrade the home to provide suitable facilities and staffing. Information about the home including fees is available from the home in the form of a brochure and the statement of purpose. The charges range from £375 for residential to £410 EMI plus £25 top up (for both) each week. Extra charges are made for hairdressing, extra toiletries, chiropody that is in addition to that provided by the PCT, holidays and outings. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two dates 06/06/06 and 09/06/06, and in total lasted about 10 hours. There was also a random inspection at the home on 06/04/06 that focussed on the requirements from the December 2005 inspection. This resulted in two requirements having extended timescales. The Regulation Inspector and Regulation Manager were invited to the home on the 25th May 2006 to discuss the proposal to apply for the Dementia category for the whole home. An application for this proposal has not yet been received by CSCI. This inspection included a partial tour of the building, observation of activities, meal times, interactions between service users and staff, medication administration, reading documents and care plans, checking staff recruitment and training records, talking to service users, relatives, visitors and staff, checking staff rotas and checking water temperatures. Eight surveys were returned to CSCI following the inspection and these included the views of some service users and some relatives. All of the key standards were assessed at this inspection. What the service does well: What has improved since the last inspection? There has been a lot of progress towards meeting the previous requirements and whilst they are not completed there is a lot of commitment by the staff and management to improve this service. The care plans are being written with much clearer instructions for staff to follow. The environment is improving such as, the hazards identified previously are now removed, repairs have been made to a number of items, hot water is available in all the rooms, some décor and furnishings have been renewed, and the home is generally better presented. An increase in staffing levels at night, to four carers, had been implemented, though was not always being met. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 6 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. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. Prospective service users will have information about the home, including a contract and an indication that the home can meet their needs following an assessment. An increase in the dependency of some service users has affected the way services are offered and needs met. EVIDENCE: A brochure was available at the home that gives some brief information about the services and facilities available. It was stated that the statement of purpose, and service user guide, were being rewritten in preparation for the application to change the registration to have all service users with dementia. An inspection report in the hallway was dated April 2005, and there have been two further reports published since that time that were not on display, so this information for potential and current service users is not accurate and up to date. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 9 Some service users were concerned about people with dementia being in the part of the home that was not supposed to be for people with dementia, and commented on the disruption that it had at mealtimes and at night. Staff members supported this and raised concerns about staffing levels not increasing when service users needs had. One person was struggling with the age and infirmity of fellow residents and felt quite isolated, particularly as his usual supporters were not available. The home must be clear about the service it provides and address these issues quickly. There were clear and informative assessments on file for each service user on admission and some reassessments more recently, including at least one person that requires nursing care that is not available at this home, and is therefore preparing to move. Prior to admission service users, or their relatives, had an opportunity to visit the home to establish if they could live there. The manager usually visits them at home or in hospital in order to establish if the home can meet the care needs. Two types of contracts are issued to service users depending on whether they are self- funding or funded by the local authority. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. The updated care plans are based on the individuals needs and give clear instructions. There are still some examples of poor practice regarding medication administration and recording. Carers were praised for being helpful and hardworking. EVIDENCE: The care plans have improved with clear actions for staff to follow and reviews that are up to date in most cases. Four care plans were seen and one was examined in detail with each element and action discussed. Some care plans were not yet fully changed, but were due for updating. This improvement meets requirements that have been outstanding for the past two years, and the carers have worked very hard to achieve this. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 11 Some service users and relatives stated that that the carers were caring, helpful and hardworking, giving attention to all. They also made comments about how busy carers were on the residential unit of the home and were concerned that sometimes they had to wait for attention and that not all carers knew how to do specific tasks, such as apply surgical stockings accurately. Generally people felt that they had good access to health care services and were particularly pleased with the weekly visit by the local GP, who also makes time to discuss concerns with relatives if appropriate. Community nurses were also praised for their care and provision of equipment, and support to the staff at the home. The care practices seen at the home were respectful and personal care was carried out in private. Service users were dressed appropriately for the warm weather and were encouraged to wear hats when sitting outside in the sun in order to protect them. Medication records were seen and were not always being completed correctly, such as where a dose had been altered, it was not dated or signed, and the use of O (which it was stated meant omitted), but this was not part of the code, and no reasons were recorded for the omissions. A number of other medication records were not clear. Medication pots did not look clean. Some concerns were raised with the person in charge regarding medications delivered the day before not being properly entered, and not being locked away causing a potential hazard to service users. Some carers had attended further training in medication administration following the requirement for the December 2005 inspection, and medication auditing records were available showing that procedures were being followed, however some poor practices were demonstrated at this inspection and need to be addressed. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, and 15. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. There were some good examples of activities, outings and holidays, though service users stated that there were not enough activities. The food was enjoyed, was of a good quality and provided for special dietary needs. EVIDENCE: Some people and their relatives were very content with their lifestyle at the home. One person explained that she chose her routine for the day, had a favourite place to sit and carers were aware of her likes and dislikes for meals, bathing and other personal care. One person talked about the lovely holiday to Blackpool in an adapted caravan that she, and some other residents had been on recently, and about the outings to the coast and theatre. The Wyndthorpe News advertises the weekly quiz and Thursday film show that service users stated were very good. There is a regular religious service and visits to the local community shops or to the bowling green (in the grounds). Some reminiscence sessions were seen during the inspection and there was a collection of interesting items that prompted discussion. The hobby therapist was also doing some work with individuals, which was particularly valuable, Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 13 especially for those people with dementia who were unable to join in with group activities. Some people stated that there was not enough to do, and that was confirmed by observation and discussions with people at the home. The hobby therapist works part-time and covers both sides of the home, so it was inevitable that there would be many hours without activities for some people. Despite a programme of activities displayed on the wall, this was generally not being followed in order to do whatever service users chose that day, however it was hard for others to assist with the organisation of activities or for service users to plan their day around activities. One person, admitted under a variation to the registration, usually had some individual support for activities, but this had not been happening for a few weeks and he was very unhappy with this. This must be rectified in order for the placement to continue. Generally meals were very well appreciated, with home cooked traditional style food provided from a 4 week rotating menu. One person surveyed said ‘top marks for the cooks’, and most comments were positive. Diabetic diets were being catered for with alternatives provided and some diabetic cakes or puddings made. Some service users did comment about some aspects of the food such as sandwiches every day for tea, and mashed potatoes every day at lunchtime. The menus show that these are provided daily, though on Fridays chips were on the menu and on Sunday roast potatoes. Once a week an omelette is available at teatime according to the menu. It was not clear from the menus how service users would get the minimum of 5 portions of fruit and vegetables as recommended by the government and no additional portions were served as snacks. Another concern was that food was stated to be ‘swimming in gravy’, and this could be addressed by putting gravy boats on the table or checking with individuals about the amount. It was noted that tables were nicely set with some having teapots, milk jugs and sugar basins, and new crockery. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 14 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, and 18. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. The relevant procedures were available in the home and staff members were aware of their content and what action to take. The laundry service was the main area of concern raised. EVIDENCE: There are policies and procedures in place for staff to follow regarding complaints and abuse. A copy of the complaint procedure was displayed in the hall of the home. Complaints and concerns received by the home are recorded briefly though do not always give the details regarding the action taken and the outcomes. One complaint regarding laundry problems had been recorded since the previous inspection, but it was unclear if it was resolved satisfactorily. Training has been provided to staff members on customer care and the Protection of Vulnerable adults, and when questioned they knew what do and who to report concerns to. There is an ongoing adult protection case from last year. Two relatives have raised concerns with CSCI because they felt unable to raise them directly with the home, mainly due to a defensive attitude. Some people spoken to were very satisfied with their relationship with the home and felt able to raise concerns. This inconsistency needs to be addressed, so that all Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 15 service users and their relatives feel able to talk about their concerns with ease, and have co-operative relationships with the home. Of the eight surveys returned, seven people ticked always to the question, do you know who to speak to if you are not happy, and six to the question, do you know how to make a complaint? This shows that the procedural information is probably getting to the right people, but may need some positive action to fully facilitate it. A lot of the concerns raised by relatives were regarding problems with the laundry service. The issues were about items getting lost, or being returned crumpled, delicates not being washed as such, or clothes taking a long time to be returned. The carers at the home confirmed that there have been problems with the machines at the laundry, which is located in the adjacent home. Wyndthorpe Hall and Court no longer have any form of washing machine or dryer that could help out in times of difficulty or for individuals to do their own laundry with assistance that would reduce some of the problems. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 16 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, and 26. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. The service provides a homely environment generally with a lot of improvements already and more planned such as bathroom upgrades. The designated smoking area is not a pleasant or comfortable area and may be hazardous due to stored items. EVIDENCE: The general appearance of the home is improved with some decorating and new furniture in place particularly in the communal rooms. The health and safety issues identified at the previous inspection have been addressed such as locking away the cleaning materials, hot water to all rooms, and installing radiator covers (not all in place yet). Routine services and maintenance of equipment has been carried out. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 17 The building was cleaner and tidy, especially the communal living rooms, and the bedrooms. Some bedrooms require redecoration and upgrading with better facilities, furniture, including beds, commodes and carpets. In one bedroom the back had come off the wardrobe, and another had a rusty commode. The bathrooms and toilets require complete upgrading with better facilities for people with disabilities, such as assisted baths and showers, and new flooring and decoration. The room designated for smoking is an old bathroom, still tiled, with no window, and is used to store a variety of items, which could prove to be a fire hazard. At the start of the inspection the sluice room was full of laundry bags waiting to be taken to the adjacent home, staff estimated about 3 days worth of dirty laundry, linking to the concerns by relatives stated in the previous section. Externally the building is well presented at the front with planters and hanging baskets, and is welcoming. The patio areas are accessed through the lounge or dining room, but were weedy, and the furniture was scattered around with no colourful planting in this area, and therefore uninviting to service users. Beyond the patios are extensive grounds with lawns, mature shrubs and trees providing a lovely setting, and wildlife such as squirrels and rabbits were seen in the distance. The local bowling club has a green in the grounds of the home that can be seen from the building and rear patio, and is an interesting feature for some service users. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 18 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, and 30. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. Service users are generally satisfied that the care they get meets their needs, but there are times when no one is available to immediately help them. Recruitment and training follow procedures, with some areas that need bringing up to date. EVIDENCE: The home is split in to two units physically and they are run separately regarding staffing, although there is some overlap at night and when covering for each other. Each unit has a key worker who manages a team of carers, who are responsible for providing the care of the service users on that unit. Domestic workers have identified areas of the building that they care for and they cover each others absences so are familiar with all the service users. The rotas identify the person in charge and some leadership and delegation was observed during the inspection. Usually on the Court unit there are four staff during the daytime providing care to the service users with dementia. On the Hall there are usually three staff providing care to the residents who do not have dementia, and several people from the Court that prefer to be in the Hall. This was stated to be 26 people. These staffing levels were being met most of the time, but not always. During the inspection it was noted that staff were significantly busier on the Hall and some service users had to wait for attention, such as when they wanted to go to the toilet. Relatives and staff Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 19 confirmed this, as did some of the surveys, with statements like, ‘staff have no time’, ‘carers and cleaners work hard’, ‘staff are very hard working’. Most carers work long shifts of twelve hours, and also attend a handover 15 minutes before the start of the shift (that is unpaid), showing their commitment to the service users. It is required that staffing levels are reviewed, and dependency levels considered, in order to rectify the problems on the Hall, and to provide additional staff at peak times. At night there are usually four people covering the whole of the building, as required at the previous inspection, though the rotas showed several occasions when there had only been three. Of the 26 staff, 6 had NVQ level 2 in care, 4 had level 3, and 5 were doing an NVQ, with the target of 50 of staff trained likely to be met by the end of this year. Many staff members have attended an induction course including some of the staff employed for some time, and this has helped to meet some of the mandatory training requirements. Other training attended this year includes record keeping and care plans (4 staff), infection control (4), customer care and protection of vulnerable adults (4). There is in house training for fire awareness and moving and handling, though individual records seen show that not all staff are up to date. The annual training plan was not available and should be forwarded to CSCI to demonstrate how the required training will be met. A selection of 5 staff files were seen and they contained the relevant recruitment papers that evidenced satisfactory checks on new employees for the protection of service users. The files also contained records for training attended including induction, supervisions and appraisals. Not all the supervisions and appraisals on file were up to date or to the frequency required. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35, 36, 37, 38. Quality in this outcome area is adequate, and this judgement has been made using the evidence available. Some areas of the homes management are inconsistent such as the development, supervision and leadership of the staff, and poor record keeping, such as medication. Improvements are being made and some service users are satisfied with the care they receive. EVIDENCE: The Registered Manager is Susan Howden, who has many years of care and home management experience. She has completed the Registered Managers Award and is awaiting her certificate. As part of Four Seasons Health Care, a regional manager visits the home on a regular basis and provides a monthly report to CSCI. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 21 There have been a number of improvements made to the home in the past few months that have been led by the management and there are plans to further improve the home in terms of the building, the staff training, and a probable change to the registration that will require many more improvements. The feedback from service users, relatives and staff to CSCI about the home is very mixed, and reflects their different experiences. The home should actively seek out these views on a regular basis, in a number of ways, in order to be able to directly improve the lives of the people living at Wyndthorpe Hall and Court or evidence their satisfaction. Some internal auditing has taken place, and for care planning is making a difference, but for medication it has not picked up some of the areas of concern. Advice from the supplying pharmacist, or others with more knowledge in this area could be sought. The procedures regarding handling of service users monies have not changed and there is one centrally held bank account. There are individual account sheets with all incoming and outgoing expenditure recorded. The manager checks the balances on a regular basis and the administrator reconciles the accounts with head office each month. The information provided to current and potential service users should outline how monies are managed by the home. There was insufficient evidence in care staff files that they were receiving supervision at the standard frequency of six times a year, and this may affect their practice and career development. Records kept at the home are improving, for example the care plans have clearer instructions for carers to follow. Some other records require more clarity such as accident records, medication, complaints, and daily care records. Safe working practices are generally encouraged through providing training in the relevant areas (not fully up to date), and the maintenance of services and equipment. Risk assessments are carried out and in place regarding individual service users and some aspects of the environment, in line with the company health and safety policies. The accident records highlight at least 2 to staff that were unsafe practices, and one that was preventable if exterior lighting was in situ. The accident records are very brief, often unclear and do not say if any action has been taken afterwards. A new system of auditing accidents has just been introduced, with a weekly audit of each accident by the manager and a monthly audit to establish patterns. The smoking room was noted to be hazardous due to the storage of items in the room. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 22 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 3 3 2 3 N/a 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 3 Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 23 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. 2. 3. Standard OP1 OP1 OP1 Regulation 4(b) 5 (1d) 4 (1) and 6a&b 15 Requirement Include details of how service users monies are managed in the information provided. Ensure the latest inspection report is available in the home. Ensure that the home operates to provide the services that it is registered for, and declares in the statement of purpose. Continue to update all the service user plans. Ensure all service user plans are reviewed at least monthly. Ensure that their needs are still being met by the home. Address poor medication practices identified. Complete records correctly. Follow procedures. Ensure equipment is clean. Complete installation of radiator covers to safeguard service users. Provide an action plan with timescales for the planned improvements to the environment. Improve the safety of the patio area by removing weeds. DS0000048425.V290517.R01.S.doc Timescale for action 14/08/06 14/07/06 14/07/08 4. OP7 31/07/06 5. OP9 13 (2) 14/07/06 6. 7. OP19 OP19 4a 23 31/08/06 31/07/06 8. OP19 23 (0) 14/07/06 Wyndthorpe Hall & Court Version 5.2 Page 24 9. 10. 11. 12. OP19 OP26 OP26 OP27 13 (4a) 16 (2e) 16 (2f) 18 (1a) 13. 14. OP28 OP30 18 (1) 18 (1) 15. OP36 18 (2) 16. OP37 17 Remove the stored items in smoking room that are hazardous. Address the problems with the laundry service. Provide facilities for service users to do own laundry. Ensure that there are sufficient staff members to meet the needs of service users in all areas of the home. Ensure the target of 50 of staff with NVQ level 2 or above is achieved. Ensure that all staff are given sufficient training to meet the needs of service users and to meet mandatory requirements. A copy of the training plan to be forwarded to CSCI. Ensure supervision of staff of at least 6 times each year. Provide a plan to CSCI of how this will be achieved. Ensure that records are completed accurately and give sufficient detail, especially Complaints Accidents Care plans Medications 14/07/06 31/07/06 30/09/06 31/07/06 31/12/06 31/08/06 31/08/06 31/07/08 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 OP12 OP15 Good Practice Recommendations Consider increasing the activities in line with service users wishes. Review menu choices particularly in relation to mashed potatoes, sandwiches, and fruit and vegetable content. DS0000048425.V290517.R01.S.doc Version 5.2 Page 25 Wyndthorpe Hall & Court 3. 4. 5. 6. OP15 OP16 OP19 OP33 Consider how individual choices for sauces, gravy, and condiments can be made. Consider how to assist relatives feel more at ease when raising a concern. Improve the appearance of the patio areas so that they are more inviting to service users. Seek the views of service users, and their relatives in order to improve the quality of the service provided. Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Wyndthorpe Hall & Court DS0000048425.V290517.R01.S.doc Version 5.2 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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