Inspection on 02/02/07 for Wythall Residential Home

This inspection was carried out on 2nd February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wythall Residential Home 01/11/05

Wythall Residential Home 01/07/05

Wythall Residential Home 11/01/05

Wythall Residential Home 21/06/04

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 Wythall Residential Home 241 Station Road Wythall Birmingham West Midlands B47 6ET Lead Inspector Rachel McGorman Unannounced Inspection 11:30 2 February 2007 nd 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 Wythall Residential Home DS0000018491.V329721.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. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wythall Residential Home Address 241 Station Road Wythall Birmingham West Midlands B47 6ET 01564 823478 01564 829834 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) Wythall Residential Home Limited Mrs Linda Ann McIntyre Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (22) Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One room is registered for service users who are mobile and do not have a dementia type illness. 1st November 2005 Date of last inspection Brief Description of the Service: Wythall Residential Home is registered to provide residential care for up to twenty two older people, over the age of sixty five, who are frail, who may have a physical disability, and who may experience mental health problems. The house is a large, detached property, which has been upgraded and extended, to provide a pleasant environment for the people who live there. The building is well maintained and there is garden area to the rear, which is accessible to service users. Situated in a residential area of Wythall there is easy access to public transport and the local shops. Adequate parking facilities are provided at the front of the home. The home is owned by Wythall Residential Home Limited, and is one of four homes within the group. Mr A Barwell and Mrs S Barwell are both directors of the company and visit the home regularly. The General Manager, Mrs Vanessa Nuttall provides overall supervision of the home, and support for the manager. The registered manager, Mrs Linda McIntyre, has responsibility for the day-today management of the home. The range of fees varies between £440 and £485. The philosophy of the home is to offer highly professional care with a personal touch, in a secure, relaxed and homely environment. The stated aim of the management and staff is to provide a home where individuality is emphasised, with staff who have the time to give attention to detail, and where residents can choose how they wish to live their lives. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included viewing previous reports, and documentation relating to the home, and considering the various contacts made with the home since the last inspection. The pre inspection questionnaire provided updated information about the establishment, and any recent changes that have taken place. Comments were received from service users, and their families or a representative in response to surveys that had been sent to them. The views of health and social care professionals in contact with the home were also sought. The visit was unannounced and took approximately 6 hours, when some time was spent with service users, discussing with them what is like living at the home, and observing their interactions with the staff. The care records of two service users were checked in detail for case tracking purposes, and the Medication Administration Records were also seen. During conversations with staff, comments were made about what it is like to work at the home. Two staff files were also seen. The inspector was able to speak with the staff member responsible for the maintenance of the building, and to check the records relating to the servicing of equipment, and to health and safety matters. Discussions were held with the Registered Care Manager, Ms Linda McIntyre, about her role, and the day-to-day management of the home. The General Manager, Mrs Vanessa Nuttall, also visited the home during the afternoon, and provided information on the organisational aspects. A tour of the premises was undertaken, and the extensive upgrading and development of the home over the past few years was discussed. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 6 What the service does well: A warm welcome is always given, and this was mentioned repeatedly in the comments from families, and professionals visiting the home on a regular basis. There was a lovely atmosphere and the home was calm and relaxed. There was evidence, when observing the interaction between staff and service users, that they are at the centre of everything. Residents are very obviously involved in making decisions about their daily lives, and they also confirmed that they are treated with respect and consideration at all times. Relevant information about the service, and what can be provided, is available to service users and their families, and is reviewed regularly to ensure that it is up to date and accurate, and therefore able to assist prospective residents and their families to make the right decisions about their care. The families of service users are also supported and their involvement with the home is encouraged. Advocacy is available for service users without family, to ensure their interests are protected, and enable them to express their views independently. A high standard of personal and health care is provided for each resident at the home, and the staff work well with other professionals and agencies, to help improve and maintain their health, with obvious benefit to service users. The individual needs of service users are regularly reviewed and recorded. Opportunities are available for service users to do the things they enjoy, and they are able to choose if they wish to be involved in the activities that are provided, which are many and varied. Two vehicles are available to provide transport for service users, and enables them to maintain contacts outside the home. Recruitment and selection procedures are followed, and the management is clear about the support, training and development for the staff it employs. Staff confirmed that they are given appropriate training opportunities. Residents describe the care they receive as good and the food as lovely. Relatives describe the home as providing a welcoming, caring, happy and peaceful environment and the staff as kind and helpful. The home provides comfortable rooms that are well furnished and maintained. The building has been sensitively extended and upgraded, and is maintained to a high standard. It is nicely furnished, warm, comfortable, safe and clean. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? There is an obvious commitment from everyone involved with the provision of care at the home, to the ongoing improvement and development of the service, for the benefit of the people who live there. The health and personal care needs of service users are being met more effectively following appropriate risk assessment being undertaken on admission to the home. The training programme for staff at the home has been developed, and a matrix introduced, to record the courses attended by each person, and to identify any training that needs to be done. The complaints procedure has been reviewed and amended to include all the relevant information, specifically in regard to contacting the Commission for Social Care Inspection. Infection control procedures have been reviewed and are now being implemented more rigorously, in response to previous requirements, and also to ensure that the health and safety of service users and staff is promoted and protected. The protection of service users has been promoted by the improvements seen in the administration of medication at the home, although all hand written entries should be witnessed. The additional guidance provided for staff, about not witnessing the signing of a service users will, should afford them greater protection. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 8 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. Wythall Residential Home DS0000018491.V329721.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 Wythall Residential Home DS0000018491.V329721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 6 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. Information is provided for prospective service users, to assist them in making a decision about their future care needs The pre-admission assessment provides relevant information, to ensure that the home is able to meet the identified needs of service users. The admission procedure provides an appropriate introduction to the home. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 11 EVIDENCE: A statement of purpose has been produced, which together with the service users’ guide, provides prospective residents with the relevant information to enable them to make a decision with regard to their future care needs. These documents are reviewed regularly. A statement of the Terms and Conditions of residence is provided to each service user on admission, and contains relevant information about their occupancy. The Care Manager undertakes a pre admission assessment for all prospective service users, either at home or in hospital, following the initial referral. The documents seen in the files of service users were detailed and informative, and contained relevant information to assist staff in deciding if their needs could be met at the home. There is a well-established admission procedure in place at the home. Prospective residents are encouraged to visit the home, and to spend time with the resident group, and also stay for a meal. Arrangements may also be made for a short stay, if this is preferable, before making a decision about future care arrangements. Intermediate care is not provided at Wythall Residential Home. Wythall Residential Home DS0000018491.V329721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Risk assessments are completed, to support service users in being as independent as possible. The procedures followed in the administration of medication ensure the protection of service users. The privacy and dignity of service users was respected, and the atmosphere throughout the home was one of mutual esteem and regard. Training is provided for staff to ensure a greater understanding of the issues regarding death and bereavement. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 13 EVIDENCE: The care plans provide evidence that the personal and healthcare needs of residents are being met. An individual plan of care is developed with each service user, and is based on the initial assessment undertaken during the admission process. This document is very comprehensive and covers all the aspects of care in relation to the daily living needs of the service user. It includes, a photograph, a nocturnal assessment, health and personal care details, it explores physical and emotional well-being and social interests, and the likes and dislikes of the resident and their relationships with friends and family. The document is discussed with the resident and their family, if that is their wish, and a signature obtained whenever possible. The care plans of two service users were seen for case tracking purposes. They were well maintained, and had been reviewed regularly. The actual frequency of the review is determined by the needs of each person, the inspector was told, and is at least monthly Risk assessments are completed with regard to moving and handling, and the activities of daily living, for each service user. Assessment is also undertaken for tissue viability and the nutritional needs of service users. The health care records seen during the inspection, clearly indicate that the health and personal care needs of service users are monitored and relevant action taken. The home is well supported by the Primary Health Care Team, and referrals are made when necessary, e.g. to the continence advisor. A satisfactory policy and procedure is in place at the home for the administration of medication, and support and advice can be sought from the local Pharmacist, when appropriate. The Medication Administration Records (MAR) were seen and these had been completed to a satisfactory standard, although the care manager was again reminded of the need for hand written entries on the MAR charts to be signed and witnessed in order to protect service users. A review of the medication prescribed to service users is undertaken regularly by the GP, and the content of the homely remedies list was updated recently and agreed with the doctor. One service user is supported by staff to manage her medication, and is therefore able to retain some independence in this area. A risk assessment has also been completed. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 14 Evidence to indicate that service users are treated with dignity and respect was observed in the interactions between staff and service users, and was also confirmed in discussion with several residents. Their comments included: • • • • • • • • • • I like my little place here Lots of activities are organised I’m happy with everything They make a real fuss of me The carers are always ‘on the ball’ My painted nails are just lovely Nobody is ever too busy to speak to me What more can I want The beds are always clean and fresh This place is laid back with kindness A detailed policy and procedure relating to death and dying has been produced at the home, and also includes the varying practices and beliefs that exist within a multi cultural society that would need to be observed by staff. Training on death and bereavement has been undertaken by several staff in order to increase their awareness of the issues. The wishes of service users concerning terminal care and after death arrangements are discussed with them, and their family when appropriate, and a record is maintained in their plan of care. The care manager discussed the arrangements that are being made for a service user without any family, and it was obvious that the situation is being dealt with in a very sensitive way. A multi-disciplinary meeting with advocacy services and other professional people is currently being organised, to ensure that appropriate decisions are made in the best interests of the resident. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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. The extensive programme of leisure activities provides opportunities for stimulation, and enables the social needs of service users to be met. The wishes and preferences of service users are respected, and they are encouraged to make choices about all the activities of daily living, in a way that encourages and promotes independence. Service users have complete freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained. Service users are offered a choice of nutritious, wholesome and well-balanced meals, and the records provide evidence that a satisfactory diet is taken by everyone. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 16 EVIDENCE: Residents have complete freedom of choice in regard to their contacts, both within and outside the home, and they are enabled to make choices with regard to all the activities of daily living, for example, when to get up or go to bed, and how to spend their day, or whether to join in the various pastimes. This was confirmed in conversation with service users and staff, and also in comments received from relatives. The social, cultural and recreational needs of service users are considered by staff at the home, and opportunities are provided to undertake a variety of interesting and stimulating activities. The spiritual needs of residents are also considered, and every 4 – 6 weeks a group from a local church visit the home, and hold a service and sing hymns with service users. Service users are consulted individually about their particular interests and a record is maintained. For those who wish to be involved, activities are arranged with the support of staff on an individual basis, or for group participation, either within or outside the home. Two service users particularly enjoy doing jigsaw puzzles, and a table has been set up specifically for them in the lounge. Some residents like to play scrabble, and board games and cards are also popular, while other people prefer knitting, sewing or crochet, for example. One service user likes playing darts, so the possibility of obtaining a darts board is being explored by the care manager. The inspector was told about a musical production, called ‘Magic of the Movies’, that had taken place at the home during the summer. Several of the less mobile residents were able to participate in the event, which was said to have been a great success. During the afternoon several service users were seen and heard to be enjoying a game of floor snakes and ladders with the assistance of staff. (The staff were on the floor)! In addition, birthdays are celebrated and seasonal activities organised, such as, an Easter Bonnet Parade, a Valentine celebration, a firework display, a Halloween party, a carol concert, a Christmas Pantomime, and various other things in between, including coffee mornings, a garden party in the summer, and a Christmas Fayre. Generally, the impression given was any excuse for a party or a celebration will do. One service user said, about the Halloween Party, ‘I haven’t had so much fun in years’, while another person discussing her birthday party stated, ‘It was a right good knees up’. The home has two minibuses and there are occasional trips to a garden centre for morning coffee or afternoon tea, or to town for shopping, or just for a little ride round. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 17 There are no specific visiting times and the involvement of family and friends is actively encouraged. Visitors are made very welcome, and all their comments were very positive both in person and in their written responses about the care provided to their relatives and friends at the home, and about the kindness of staff. These included the following: • • • • • • • • • • • • The management are always approachable I am made to feel very welcome Mother is looked after very well The staff are always helpful and very caring The care manager is excellent We cannot be more pleased Mom is always dressed like a million dollars The house is always clean and fresh There’s lots of stimulation I feel very confident about the care Communication is very good Every spot and blemish is noticed immediately The arrangements regarding the provision of food reflect the individual likes and dislikes of each service user, and food is always an agenda item at residents meetings. Service users were all very complimentary about the lovely food, and meals were observed to be a social and leisurely occasion. The menus indicated that lunch is a set meal, with an alternative available, and at supper time there is always a choice of a hot or cold meal. Several service users said that they preferred sandwiches in the evening. Today there was a choice of brown or white bread and a selection of fillings with salad garnish, or a baked potato with beans or cheese. Fresh fruit is also available at any time. Several comments were made about the ‘superb food’ that is always served at the home, and one person said they would like their compliments passed on to the catering staff. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 18 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): 16,17 & 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 implemented at the home in an open and efficient manner. Service users legal rights are protected through the robust policies and procedures that are in place. The policy and procedures in place at the home relating to abuse, and the training provided for staff, should ensure the protection of the people who live there, and who may be vulnerable. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 19 EVIDENCE: A clear procedure for investigating complaints has been developed, and any issues are dealt with immediately. Service users and their families confirmed that they felt confident that any concerns raised with the management of the home, would be listened to and addressed in an appropriate way. People felt that their views were welcomed. There have been no complaints about the service during the past year, but neither were any compliments recorded in the log. The care manager was encouraged to record all comments made about the home and the care provided, to give a more balanced view of the service. The policies within the home acknowledge the rights of service users in every respect, and residents are assisted to access medical, legal, advocacy and civic services depending on their individual needs and wishes. Arrangements are made for postal voting where service users are not able to attend the polling station in person. Policies and procedures for protecting service users have been produced and the Adult Protection Procedures were implemented appropriately, a few months ago, by the management of the home, during an investigation into the alleged abusive behaviour of a carer employed at the home. A member of staff was subsequently dismissed on the grounds of gross misconduct. The need to review the procedures in relation to staff who may be unsuitable to work with vulnerable people was discussed with the care manager. Training has been provided for staff, to increase their awareness of the many aspects of abuse, and staff confirmed their understanding of these matters during discussions with them, at the time of the visit. A previous recommendation that staff should be informed that they are not permitted to witness the wills of service users, has now been met, and is included in the guidance provided for staff. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 20 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): 19,20,24 & 26 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. Service users live in a well-maintained house that is clean and comfortable, attractively decorated and furnished, and in an environment that is safe and secure. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 21 EVIDENCE: Wythall Residential Home is a large, detached property, which has been sensitively developed and upgraded, to provide a pleasant and relaxing environment for service users. Several people said how much they liked living at the home, and one resident commented on how lovely and warm the home is, which gives it such a ‘cosy, homely feeling’. The communal areas of the home are spacious and airy, and include an extended lounge, where a variety of activities can take place, and a nicely furnished and uncluttered dining room, with both square and circular tables that provide more choice for service users. The grounds, although not extensive, are accessible to service users, and consist mainly of patios, where tables with umbrellas and chairs are provided, for residents to be able to relax outside when the weather permits. There are numerous plants and shrubs, and also bedding in tubs and pots are a feature during the summer months. The purpose built ground floor extension, to the rear of the property, has provided seven large bedrooms, which all comply with the National Minimum Standards for new build accommodation. They are furnished and decorated to a high standard and each has a french door that provides access to the garden. Service users are encouraged to personalise their rooms, and those seen by the inspector were looking lovely. With the exception of one room on the first floor, known as the flat, all the registered accommodation is on the ground floor. There are eighteen single bedrooms, nine of which have en suites, and two double rooms, one with an en-suite facility. The policy of the home is to only let rooms on a shared basis if this is the wish of both service users. The home is clean and fresh throughout and staff confirmed that they are familiar with the procedures regarding the control of infection, and that they have also been given training in health and safety matters. There were several requirements from the last inspection, relating to hygiene and infection control matters, all of which have now been met. New carpets have been fitted in some parts of the home, and there is a rolling programme of redecoration. Discussions with the member of staff with responsibility for the upkeep of the property, confirmed that everything at the home was in good working order, and that several items of equipment had been replaced recently. A new bath hoist has been purchased, a toilet seat replaced, three rooms had new vanity units fitted, and two new vacuum cleaners have also been provided. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 22 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 & 30 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The home is adequately staffed with employees who are experienced and competent to care for older people. Service users are supported and protected by the recruitment and selection procedures that are implemented by the management The training programme for staff ensures that each member of staff has a clear understanding of their role, and is able to provide appropriate care for service users. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 23 EVIDENCE: The staff rotas indicated that staffing is maintained at a level that is adequate for the needs of service users. There is a minimum of two care staff and a senior on duty throughout the waking day, and during the night there are two waking carers with a senior on call. In addition, the care manager is on duty during the day, and the home also employs catering, domestic and maintenance staff. Agency staff are not used at the home. Service users and their families confirmed how happy they are with the standard of care provided, and related this to there always being enough staff on duty. One person has commented that staff ‘always had the time’, to spend with them, and that, ‘nothing was too much trouble’. There have been some staff changes during the last 12 months, although the group is fairy stable, and the majority of staff have worked at the home for several years. The staff with whom the inspector spoke, confirmed that they enjoy their work, and all were very positive about being employed at the home, and also about the training opportunities they are given. The files of two recently appointed members of staff were inspected, and the correct procedures appeared to have been followed, in regard to recruitment and selection. Relevant information was recorded and appropriate documentation was in place, and included evidence of Criminal Record Bureau (CRB) checks undertaken prior to employment, the applicants CV, references, proof of identity, and training certificates that provided evidence of qualifications. The inspector discussed an omission with the management, in regard to the pre printed request for a reference, which does not include the name of the organisation asked to provide a reference, and was assured that this would be rectified. A staff training plan has been produced in the form of a matrix, to record the courses attended by each person, and to identify any training that needed to be done. The records indicate that ‘core’ training has been provided for staff in health and safety, basic first aid, fire safety, basic food hygiene, and moving and handling. In addition, some staff have attended training sessions on the administration of medication and abuse awareness. There is also a commitment by the management of the home to the National Vocational Qualification (NVQ) training. There are five staff employed at the home with the NVQ Level 2 in Care, and two staff have the NVQ Level 3. Two people are working towards Level 2 and a further two staff are doing Level 3. Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 24 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): 31,33,34,35,36 & 38 Quality in this outcome area is good This judgement has been made using available evidence, including a visit to this service. The Registered Manager is very experienced, and qualified both in management and care, which is of benefit to both service users and staff. The quality assurance system, when fully implemented, will ensure that the home is run in the best interests of the service users. More frequent arrangements for the formal supervision of staff will ensure an understanding of their role within the home, and that their career development needs are identified and met. The health, safety and welfare of service users and staff is promoted and protected in respect of all safe working practices Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Registered Care Manager, Ms Linda McIntyre has responsibility for the day-to-day running of the home. She has many years experience in the caring profession, and has worked at Wythall Residential Home for the last eight years. She holds the Registered Managers Award in both management and care. The care manager receives support from Mr and Mrs Barwell, the Responsible Individual and his wife, who visit the home regularly, and also from the General Manager, Mrs Vanessa Nuttall, who has previous experience in managing the home. A quality assurance system has yet to be fully implemented at the home. A survey has been developed for service users, who are asked to complete questionnaires from time to time, although an audit is not undertaken. The views and opinions of service users and their families, are taken into consideration at all times, and this was confirmed by everyone with whom the inspector was in contact, but a more consistent approach is required. A formal system for measuring how well the home succeeds in achieving the stated aims and objectives now needs to be introduced, and the results audited and published annually, with a copy submitted to the Commission. The insurance arrangements for the home and the business are satisfactory, as evidenced by the certificate. A business and financial plan for the establishment was not available at the home, therefore this should be produced and a copy submitted to the Commission. Staff do not have responsibility for managing the financial affairs of any service users. The family or a representative deal with any financial matters, on behalf of service users who are unable, or do not wish to manage their own affairs. Safe storage of valuables is available, and appropriate records are maintained. Formal supervision sessions have been introduced for care staff, although the frequency needs to be increased to ensure that they are organised at least every two months, and a record of the discussion should be maintained. A health and safety policy and procedure is in place, and all staff are trained in safe working practices. Contracts are in place for the servicing and maintenance of equipment at the home, and the records are well maintained with all the appropriate certificates available The fire log indicated that fire safety checks are being carried out, the fire risk assessment for the home is up to date and fire drills are undertaken. The Accident records had been completed appropriately, notifications are made to the Commission, when appropriate. Wythall Residential Home DS0000018491.V329721.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 18 2 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 3 2 X 3 Wythall Residential Home DS0000018491.V329721.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 Standard OP33 Regulation 24 Requirement A quality assurance system must be implemented fully to measure how effective the service is in meeting the aims and objectives (Previous requirement not fully met) Care staff must receive formal supervision at least six times a year (Previous requirement not fully met) Timescale for action 31/03/07 2 OP36 18 31/03/07 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. 3 Refer to Standard OP9 OP16 OP18 Good Practice Recommendations MAR sheets that are hand written should be checked by a second person and the entries double signed. All comments, concerns and compliments made about the service should be recorded A policy and procedure should be produced in relation to staff who may be unsuitable to work with vulnerable adults, and who may need to be considered for inclusion on the POVA register The document used to request a reference from a previous employer, should include the name of the organisation DS0000018491.V329721.R01.S.doc Version 5.2 Page 28 4 OP29 Wythall Residential Home 5 OP34 A business and financial plan for the establishment should be produced, which is reviewed annually Wythall Residential Home DS0000018491.V329721.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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