CARE HOMES FOR OLDER PEOPLE
Wynfield House 115 Newton Drive Blackpool Lancashire FY3 8LZ Lead Inspector
Jackie Riley Unannounced Inspection 22nd July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wynfield House DS0000009729.V369494.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. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Wynfield House Address 115 Newton Drive Blackpool Lancashire FY3 8LZ 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) 01253 392183 Blackpool & Fylde Society For The Deaf Mr Mark Greenhalgh Care Home 19 Category(ies) of Sensory impairment (19) registration, with number of places Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 19 service users to include: *up to 19 service users in the category of SI (Sensory Impairment) 16th July 2007 Date of last inspection Brief Description of the Service: Wynfield House is registered under the Care Standards Act 2000, to offer accommodation and personal care to up to 19 adults with a sensory impairment. The accommodation consists of 7 twin bedrooms and 5 rooms for single occupancy. There are 2 lounges on the ground floor and a dining room. A passenger lift operates between the ground and first floor. The home is relatively close to local amenities and facilities with good transport links. In appearance the premises blend in with the neighbourhood. There are spacious gardens to the rear of the property that are well maintained, some of the residents like to help in the gardening activities. The home has a Statement of Purpose and Service User Guide providing information about the care provided, the qualifications and experience of the owners and staff and the services residents can expect if they choose to live at the home. The current fees per week are £357.12. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 Stars. This means that people who use this service experience Poor quality outcomes.
This was an unannounced visit that took place on the 22nd July 2008, over a period of approximately 5.0 hours as part of the inspection process. We spoke to the registered manager, who is in day-to-day control of the home, five staff members, four individual residents and a group of residents in the lounge. Residents living at the home have a range of conditions associated with sensory impairment, and some were found to have difficulty communicating, however an interpreter was available for part of the visit so that the views of people who use the service could be communicated so that they were not disadvantaged. The comments made in this report are based upon what we saw and who we spoke to, other comments will be included from other sources such as staff and relatives as well as from surveys received prior to the site visit to the home. During the time spent at the home we made general observations of the interaction between residents, staff and management. We talked to people using the service, and asked staff about those peoples needs. We also looked at care plans, records, and daily notes for three people, this is called case tracking. We also toured the home to look at the environment. Every year the person in charge or manager is asked to provide us with written information about the quality of the service they provide, and to make an assessment of the quality of their service. We use this information, in part, to focus our inspection activity. There were some responses from surveys sent to people who use the service for their views on how the home is run. The records of three members of staff were also looked at. What the service does well:
We found the home is run in a flexible manner for the benefit of people who live there. Some residents have lived at the home for a number of years and have developed friendships, which was seen to be evident throughout the time
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 6 spent at the home. Comments included, “Staff and management do appear to be supportive of the residents and have a caring manner”, “I like to help out in the garden, doing crosswords, watch TV and washing and drying dishes”, “I come and go as I please, its very flexible”, “We can go to bed and get up when we want to, its not a problem”, “My family come any time”, “the staff are very helpful”, “they are very nice people who work here”. We talked to staff members who confirmed they have a good knowledge of the individual care needs, social and cultural needs of residents living at the home so that they are not disadvantaged in any way. Comments included, “ we know the residents needs because most of them have lived here for a long time”. “Its very flexible how we work because all the residents are different”. What has improved since the last inspection? What they could do better:
The care plans looked at did not have photos of the individual residents which would be recommended so that they are more easily recognisable for staff when putting information onto the records. One file seen did not have evidence of reviews taking place to monitor the residents needs, which may disadvantage the resident as any changes have not been recorded. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 7 Residents files looked at were not in order and made the information difficult to follow. In addition some records had not been signed or dated making it difficult for staff to note when records have been updated and by whom. The use of flashing lights in resident’s bedrooms to acknowledge staff or visitors entering is strongly recommended as in the previous report so that resident’s rights to Privacy and Dignity are upheld. Steps should be taken to make sure there are no offensive odours in any parts of the home so that it is a pleasant environment for people to live in. The homes heating system was on even though the weather was very warm outside. Residents told us that it is always warm but the windows are open for a through draft. The manager told us there was a problem with the heating system resulting in the hot water not working effectively if the heating is switched off. We informed the manager this was not acceptable and action must be taken to rectify the situation to ensure the homes heating is controlled to make the environment comfortable for all users of the service. Action was being taken to rectify this situation before we left the inspection. Staff rotas show that care workers are working at least one fourteen hour shift a week but often this would extend to two. Whilst there are satisfactory numbers of staff on duty we say the home would benefit from additional care staff so that staff do not work excessive hours for the benefit of all users of the service. We saw the records of one staff who had been employed to work in the home prior to references being in place thereby having the potential to put people at risk. In addition there was limited evidence of induction training taking place for newly recruited staff. We were told they were held on a database, which was not accessible at the time of the inspection, however these records must be available for inspection at any time. Whilst we were told there are staff and residents meetings, we did not see any evidence of a formal quality assurance and quality monitoring system which would ensure the homes stated aims and objectives are being met to improve the service for all stakeholders. We looked at the homes accident records, which were available for inspection. We found they were not completed correctly in that they were not sequential and also there is one book missing for the year 2007. It is essential a complete record of any accidents be made so that a clear audit of information regarding the incident is maintained. We found the registered manager had limited control in the decision making processes on a day-to-day basis. This included not having control of staffing rotas showing how the home is staffed. Unable to use resources to repair the heating system. Not having the autonomy to ensure Gas, Electric and fire
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 8 systems are reviewed within the necessary timescales resulting in a potential unsafe environment. We saw the Gas, Electric and Fire systems had out of date servicing contracts having the potential to put people at risk. 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. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted to the home following a full assessment of need so that the home can provide the care necessary for the individual. EVIDENCE: We looked at the records of three resident’s, most had assessment details recorded, so that staff had an insight into what the needs of residents are and how they will be met, however in some instances residents had lived at the home for over ten years and therefore initial assessment information was not available, this was made up for in current assessment needs of the resident carried out by the home. Some of the records had not been signed or dated thereby reducing the ability to audit the records. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 11 We talked to the manager who said they like to visit a prospective resident prior to admission to the home to make sure the home is suitable to meet the needs of the resident. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home takes into account the health and personal care needs of residents living there, however not all records were up to date, having the potential to disadvantage people. EVIDENCE: We looked at three care plans. None of them had in place a photo of the resident on file as required by regulation and to assist staff in clearly identifying a resident’s file from the photograph. They were found to include, information about the residents health and personal needs. The way the files were maintained did not provide a sequential order thereby making it difficult to follow the information and having the potential to disadvantage people. Staff spoken to say they were used to working with the filing system, however we recommended this is reviewed so that the information is clear and easy to follow for staff using the files.
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 13 Two of the three service user records have been reviewed. They provided evidence of how individual changes have been made so that the staff team can follow this guide and meet the needs of the residents. However, in one instance there was a lack of reviews being recorded by a key worker thereby having the potential to disadvantage the resident. We spoke to the manager about this, and whilst it is recognised the staff team are aware of the individual needs of the residents as many of them have lived in the home for many years, there is a requirement to make sure all the needs of the residents are recorded so that a good level of care can be provided by an informed staff team. There was evidence on all files seen that risk assessments are taking place so that people are protected. The risk assessment takes into account moving around the home and personal risk. We saw in all instances residents have access to other healthcare professionals including a doctor and district nurse, so that their individual health needs are being met. Comments included, “The doctor comes if we need him”, “the district nurse comes in twice a week”, “we have a good relationship with the doctors surgery, with the district nurses and the doctors” We saw staff speak to residents sensitively and with respect. They were seen to use sign language so that people living at the home were not disadvantaged by way of communication. Staff we spoke to are aware of the need to make sure residents rights to dignity and privacy are maintained. They were seen to knock on doors before entering, and in addition waving their arm to attract the attention of the resident before entering, however this would be assisted by installing a flashing light system so that residents would have their privacy and dignity ensured by such a system. We looked at how the home manages the medication system for storage and administration. There is a locked medicines cabinet situated in a locked office and secured to the wall for the safe storage of all medications used in the home. Staff we spoke to had a good knowledge of the system and felt confident in carrying out administration of medication. Comments included, “we’ve had meds training and at least three of us are trained nurses”. We looked at the medication records of three people we were following during the inspection process. Their medication records were complete and recorded well, by staff who have received training in medication administration and recording. Wynfield House DS0000009729.V369494.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 good. This judgement has been made using available evidence including a visit to this service. People who live at the home have a variety of choices in respect of taking part in a range of culturally and age appropriate activities, so that their lifestyle aspirations are met. EVIDENCE: There is a dedicated cook at the home; members of the staff team are responsible for the preparation of food. We saw a varied menu, which is flexible to meet the individual needs of residents living in the home. Comments included, “every meal is good home cooked food”, “I eat very little but able to have any choice”, the food is very good they are always making cakes and baking”, “There is plenty of it, and its good””. We observed the lunchtime meal, which was seen to be enjoyed by all residents. The dining experience was seen to be a positive one and one where residents communicate freely with other residents and staff. Special diets can be catered for including low fat and diabetic controlled diets.
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 15 There is a flexible activity programme in place, based upon what the individual choices of the residents are. Staff said to us that they like to take things day by day depending on the choice and mood of the residents. We spoke to a resident who goes out on a daily basis and likes to go to the local social club and pub with a friend. Other residents who have limited mobility are assisted by the staff team to carry out various tasks or activities. We were told there are regular trips in a mini bus made available to them. We saw some residents go out with their relatives when they visit as was occurring at the time of the inspection. We saw service users using all parts of the home freely with no restrictions. The weather was inclement and therefore no residents were using the rear garden, which is large and private. The gardener was spoken to who said he works hard to make sure it is a pleasant area for residents to use. There was a range of seating for residents and their visitors if they choose to use the garden. One resident spoken to said he liked to go into the garden in the good weather and potter about. We saw there were no restrictions on visiting by relatives or friends. Two visitors were spoken to during the inspection and said they felt welcomed when they visit. Wynfield House DS0000009729.V369494.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 home has procedures in place for the protection of people living there. Staff are trained in managing the concerns and complaints raised as well as safeguarding issues. EVIDENCE: The home has a complaints procedure, which is made available to them or their relative or advocate during the admission process. All surveys we received confirmed people are aware how to make a complaint, one comment said, “I’ve never had to make a complaint her” “my daughter would know what to do”. We spoke to three members of the staff team, they confirmed they know how to deal with complaints and we found there is an open system of communication so that any concerns raised are dealt with by the manager at the time of the concern. There were no concerns recorded at the time of the site visit. Comments included, “we pass on any complaints to the manager or senior staff”. There have been no complaints received by the commission in the previous twelve-month period.
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 17 The home has a procedure in place for dealing with allegations of abuse. Staff spoken to are aware of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect, and have received training in this area. Staff comments included, “we have had training in safeguarding people, and know the system”. Wynfield House DS0000009729.V369494.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): 19,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes environment is maintained to a satisfactory standard however lack of heating control means that the home is not always comfortable for the people who live there. EVIDENCE: We looked around the home. It is designed to be homely and comfortable for residents to live in. It is a Victorian detached property with many of the original decorative features in place which residents spoken to said were very nice. There are a range of aids and adaptations including a passenger lift, shower facilities as well as baths so people have a choice of how they wish to be bathed.
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 19 Resident’s rooms were seen to be personalised, and some residents said they like to use their rooms whenever they choose. This was seen to be the case with two residents during the inspection. One resident said they choose like to use their room because they have a computer and other systems they like to use. Staff spoken to say they encourage residents to personalise their rooms so that they feel homely with personal possessions around them. We found the homes heating system is not fully operational in that the heating was on even though it was a very warm day outside, residents said the home is always to warm but windows are usually open to let a draft through the home. When we spoke to the manager about this issue we were informed the heating is continuously on because if turned off the hot water is not working effectively. We informed the manager this was not acceptable and did not help to make a comfortable environment. There are procedures in place for infection control and to ensure the home is hygienic, however there was one area of the home with offensive odours and this was discussed with the manager and domestic staff. We were informed there are plans in place to replace carpeting, which may harbour the odour and would improve the area of the home for the benefit of people who use the service. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 20 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. Staff display knowledgeable and skills to meet the needs of people with a sensory disability, however not all staff had received complete reference checks prior to employment and in addition are working excessive hours, thereby having a possible detriment on the people who use the service. EVIDENCE: We looked at three staff files as part of the inspection process. In one instance a member of staff had been employed prior to suitable references being returned to the home, in another instance interview records were not available for inspection to demonstrate how the decision making process for deciding an applicant was fit to work in the home. Both these areas are essential to demonstrate a person is safe to work with people who may be vulnerable. We found that the home is committed to ensure the staff team receive training in areas of care suitable to meet the needs of people with sensory impairment. All but two staff have completed basic British Sign Language training and the remaining two staff are enrolled on the annual training course due to commence in September this year. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 21 The manager told us that staff induction takes place for all staff. This was confirmed by talking to two staff members on duty who said, they are told about the homes routines and shadow another senior member of staff. However, there were no induction records available at the time of inspection. It is a requirement that induction records are maintained and available for inspection. We spoke to a number of staff during the inspection process and received comments from surveys. Staff members said they have received various training courses, including medication training, moving and handling and safeguarding procedures. Those spoke to were know legible about the individual needs of residents living at the care home. The home is staffed according to meet the needs of people living there, however we noted from the staffing rota and by talking to members of staff, that care staff regularly work at least one fourteen hour shift a week, with most weeks working two of these long shifts. We found there is an expectation staff will work these hours. Whilst we acknowledge the home is adequately staffed on a rota basis, there should be additional staff available so that members of the care team are not expected to work excessive hours, which may have a negative impact on the level of care being delivered to residents. Staff comments from discussion and surveys included, “we work long hours, it is expected of us and the fourteen hour shifts are long days”, “we could do with some more staff so we don’t have to work such long hours”, “we work well as a team, and we are all key workers for individual residents”. Residents we spoke to thought highly of the staff team comments included, “the staff know how to communicate with us, even though we are deaf”, “the staff are very nice”, “the staff are very helpful”, “they are very nice people who work here”. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes manager is qualified and experienced, however limited resources mean that essential maintenance work is not being carried out in a timely manner having the potential to pose risk to people who use the service. The registered manager does not have the delegated responsibility to take action to ensure the home is run for the benefit of people who use the service. EVIDENCE: We looked at how the home is run for the benefit of people who use the service. We found the homes registered manager is limited in the autonomy he has regarding decision making. This was seen in the staffing rotas where we recognised staff are regularly working over and above the contracted hours.
Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 23 The manager was unable to recruit more staff. We found the home gas, electric and fire servicing checks were out of date and the manager was unable to access servicing of this equipment independently. The need for attention to the heating and water system was recognised by the registered manager as a problem, however he was unable to instigate repairs to this system without authority from the charitable board. Whilst there is no obvious sign of limited resources in the care of residents, there was evidence the registered managers line of accountability is affected by external management. We found there is an informal approach to quality assurance in that we were told there are meetings for both residents and staff although no records were available for inspection. We were told there are a quarterly and annual business meetings however there was no evidence of the meetings held ion the homes premises. We say there should be some formal system whereby the home is monitoring and reviewing its stated aims and objectives for the benefit of people who use the service. The way the home looks after people money was looked after and found to be recorded individually and audited so that it is safe. We looked at how the home ensures the health safety and welfare of all stakeholders of the service. We found staff are trained in fire procedures, food hygiene, infection control and first aid. We looked at the servicing of equipment including Gas, Electric and found servicing of equipment was out of date. We discussed this with the manager who contacted the general manager and agreed the work would be carried out within a seven day period however this did not occur, resulting in potentially putting people at risk. We looked at how accidents are recorded. Whilst there is a record of accidents occurring to both residents and staff, the records are completed incorrectly by not following the instructions. We found they were not sequential and also there is one book missing for the year 2007. It is essential a complete record of any accidents is made so that a clear audit of information regarding the incident is maintained. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 1 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 3 X X 1 Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 16(2)(k) Requirement There must be attention given to the first floor room, which was found to have an offensive odour, so that it is a pleasant and odourless area for the resident to live in. The heating system must be in good working order so that the residents can control the temperature and the homes environment is comfortable at all times. Staff working in the home must have in place references prior to commencing work in the home for the health safety and welfare of other users of the service. There must be records available for inspection at all times, in this instance in respect of staff induction records. The homes electrical system must have a current certified certificate showing that the system is safe for the safety protection and welfare of users of the service. There must be evidence of the Gas system being serviced within
DS0000009729.V369494.R01.S.doc Timescale for action 15/09/08 2. OP25 23(2)(p) 31/08/08 3. OP29 19(1)(b)(i ) 31/08/08 4. OP30 19(1)(b)(i ) 23(2)(b) 31/08/08 5. OP38 31/08/08 6. OP38 23(2)(b) 31/08/08 Wynfield House Version 5.2 Page 26 7. OP38 23(4)(iv) 8. OP33 24(a)(b)( 3) the stated timescale of the most recent certificate so that it is safe for the health safety and protection of all users of the service. The homes fire equipment must have in place a current certificate for use so that the health safety and protection of all users of the service. There must be evidence the home has in place an effective quality monitoring and quality assurance system, based upon seeking the views of users of the service to ensure it is meeting the stated aims and objectives of the service. 31/08/08 01/10/08 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. 3. 4. 5. Refer to Standard OP7 OP19 OP27 OP7 OP32 Good Practice Recommendations All care records should be kept in an organised condition so that they are sequential and easy to refer to individual areas when needed. There remains a recommendation for flashing lights to be place in resident’s rooms to indicate a visitor, so that their privacy and dignity is upheld. The staffing levels should be reviewed so that staff do not have to work excessive hours to ensure the home is staffed by people who are fit to carry out their roles. All Service User Plans should include a photograph of the resident for ease of identification. There must be evidence of the registered manager having access to resources, which ensure the health safety and welfare of users of the service, and to be able to make decisions based upon good practice and the needs of people who live and work at the home. Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 27 6. OP7 All residents should have their care plans reviewed at least once a month to update any changes and reflect their changing needs Wynfield House DS0000009729.V369494.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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
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