Inspection on 20/11/07 for Wyton Abbey

This inspection was carried out on 20th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wyton Abbey 27/11/08

Wyton Abbey 11/06/07

Wyton Abbey 06/05/06

Wyton Abbey 17/10/05

Wyton Abbey 11/04/05

Wyton Abbey 18/11/04

Wyton Abbey 10/06/04

Wyton Abbey 08/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wyton Abbey Wyton Bilton Hull East Yorkshire HU11 4DJ Lead Inspector Ms Wilma Crawford Key Unannounced Inspection 20th November 2007 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 Wyton Abbey DS0000019777.V355384.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. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyton Abbey Address Wyton Bilton Hull East Yorkshire HU11 4DJ 01482 817610 01482 815604 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Ltd Kim Dixon Care Home 33 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (33), Old age, not falling within any other of places category (33) Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category Dementia (DE) relates to 5 service users aged between 50-65 years, and one named individual aged 40-50 years (application V30433 refers) The Garden Cottage, which is an unstaffed facility, accommodates up to 3 independent service users, who may access the facilities of the staffed home daily and in an emergency at any time. 11th June 2007 Date of last inspection Brief Description of the Service: Wyton Abbey is a large house set back from the main road, in its own grounds, adjacent to the village of Wyton, in the East Riding of Yorkshire. The house is a listed building, has extensive grounds with a small walled garden area for service users to sit in and a large car park for approximately 10 cars. Access to public transport is from the adjacent main road, which is a short walk along the home’s driveway. Prime Life Ltd owns the home, which is registered for 33 service users of either sex, the majority of whom are over 65 years of age; Six service users may be under the age of 65 years and some service users may have dementia. The majority of the bedrooms are single with five bedrooms being shared. The adjacent Garden Cottage has three service users’ rooms for service users who are more independent. Services provided include personal care, meals, laundry and health care, with additional health services being accessed as necessary, for example, the district nursing services. Fees: £310.80 - £455 per week. This information was provided by the manager. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 11th June, including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours including preparation time. Four people living in the home, and two staff were spoken with during the visit. The manager was available throughout the visit. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of three residents and two staff were inspected. An Annual Quality Assurance Assessment (AQAA) document asking for information about the home was sent out before this visit and information from this was included as part of the inspection process of this service. 36 surveys were sent out to people living in the home and staff, 3 of these were completed and returned. The comments from these and from discussions during the site visit are also included in the report. What the service does well: What has improved since the last inspection? Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 6 The manager has worked hard to address the large number of requirements that were made at the previous inspection. The manager is now registered with the Commission for Social Care and Inspection. A new care planning system has been introduced which is more detailed and comprehensive and includes an information sheet which identifies what help people living in the home need and how they would like to be supported to have these needs met by staff. Although not all care plans have been transferred onto this system, there has been a review of all care plans to ensure they still meet the individuals’ needs and wishes. A new assessment process is being used by the home for all referrals made. Within this assessment the risk of pressure sores is identified. These changes in the assessment process should help ensure that people who use the service to be confident that their needs can be met. There is also recorded information demonstrating that people and their relatives have been involved in the pre assessment process and the development and implementation of their care plan.These have been signed by the individual or their relative. The terms and conditions provided by the home now include details of what additional charges are made, but do not include details of the costs of these. However, the individual contract for each person identifies what costs would be made to the person, ensuring that people have the necessary information about the full costs that they are expected to pay. The manager has been provided with training in Dementia, Alcohol related dementia, a certificate in the care of vulnerable adults, and a managers’ awareness course in the protection of vulnerable adults. The staff team have also attended training in Dementia and the protection of vulnerable adults, which has developed a better understanding of the needs of people with Dementia and the staff teams’ individual role in the referring of safeguarding issues, further supporting the protection of people living in the home. The manager and senior staff that have responsibility for the administration of medication have received training, providing them with the knowledge and skills to promote and protect the service users, health and safety. Training on Diabetes has been provided to the senior staff by the Community District Nurse. Staff are appointed only after the appropriate recruitment checks have been completed. What they could do better: The two sluices in the homehave been out of use for some time and waThe replacement parts for the two sluices in the home have still not been obtained. This has been an ongoing issue for a long time waiting for replacement parts to be obtained. The staff are having to hand wash the commode pans which is unhygienic and this continues to present a risk of ‘ splash’ into their eyes. Although the manager has regularly contacted the maintenance department she has still not been given dates of when the parts will be available and installed or the sluices will be replaced. Adequate arrangements must be in Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 7 place to ensure hygiene and infection control is maintained and staff’s health is protected. The flooring to the ground floor is a polished surface that is discoloured as a result of many layers of polish having been appliedover a peiod of years. The manager has been manually removing this to improve the appearance of this and for the people with Dementia, some of who did not like to walk across these areas as they can perceive such areas to be a hole or water. Although progress has been made with this, there is still considerable work to be done to complete this. Rather than the manager spend some of her time removing this, the organisation should consider how the remainder could be removed quickly, to improve the environment. The plaster surrounding the door to the staff room is loose and needs to be repaired or replaced. Although this had been reported to the maintenance department, (no date for this to be replaced has been provided.) Although the overall cleanliness in the home is satisfactory, there are identified areas that have deteriorated, with some staining of carpets and identified odours in lounges and bedrooms. The domestic staffing levels in the home need to be reviewedto ensure that there are adequate hours available in the home to ensure that all necessary tasks are completed, including the cleaning of carpets and soft furnishings are maintained to provide people living in the home with a clean and odour free environment. The organisation should consider how the maintenance department can improve communication with the manager by informing her of reasonable timescales in which reported faults are to be dealt with and if this is not possible when further discussion will take place as to what the next stage of the process will be with identified timescales. Training in the assessment process should be made available to the homes manager. 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. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4and 5. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are provided with information to enable them to make a decision about the home and if it is right for them. EVIDENCE: A pack of information including a brochure, statement of purpose and terms and conditions is given out to all people who enquire about placement at the home. The terms and conditions provided by the home now include details of what additional charges are made, but do not include the details of costs e.g. en – suite room. However, the individual contract for each person identifies what costs would be made to the person, ensuring that people have the necessary information about the full costs that they are expected to pay. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 10 Discussion with staff and people living in the home demonstrate that they had the opportunity to visit the home and had been provided with information about the home before making a decision to move in. One individual said that they had been in hospital, but their family had visited on their behalf. Checks of a sample three files showed that each individual has either a local authority contract in place or the homes terms and conditions for privately funded individuals. At the previous inspection a requirement was made in respect of the manager being offered training from the company to be able to undertake assessments in the community for people wishing to be placed at Wyton Abbey. The manager said she has not had formal training on the assessment process since she moved from her senior care position to that of manager in April 2007. In her previous role she had accompanied the previous manager and watched the process being carried out. The responsible person must make sure the manager receives the necessary training to be able to complete the needs assessment process in an efficient and effective way, and that the needs of the prospective resident and those of the people living in the home are taken into consideration before a placement is offered. Each resident has their own individual file and three of those looked at have a full needs assessment from Social Services completed within them. Since the last site visit the staff team have completed training in Dementia, which they said has given them a better insight and understanding into the condition and the associated behaviours. The manager has also attended training in Dementia and alcohol related Dementia. During the visit staff were observed to assist people living in the home in a supportive and caring way. The home also had a much more relaxed and calm atmosphere than there had been at a previous visit made by a different inspector. Comments from the surveys completed as part of the home’s Quality Assurance System in September 2007,indicate that those relatives and residents who responded are satisfied with the care provided. One individual said ‘the staff are always very helpful, understanding and caring’ another said ‘All of the staff are great, nothing is too much trouble for them. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health and personal care needs overall are supported by detailed care plans and risk assessments. EVIDENCE: There has been a recent review of the care planning system within the home and as a result of this a new updated system has been introduced. The new system is computerised and a printed copy is kept in each individual’s file. This makes it easier to update the information and print off sheets in areas where changes have been identified. Presently not all service users’ care plans have been transferred onto this system, but those that have not have been updated according to individual need and include a sheet which identifies with the individual to determine if they have been involved in a discussion about how their needs and wishes could be best met, their involvement in the review of their care plan to establish if their needs and wishes are still being met, and Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 12 their involvement in the pre assessment process and the implementation of their care plan. Each was signed by the individual or by their representative on their behalf. The new style care plans are more detailed and comprehensive and offer clear guidance on how people want their support to be offered and how staff can provide this. Each area of the care plan has an evaluation sheet which is completed on a monthly basis or sooner if required. Details of G.P. opticians, District Nurses and chiropodists visits are also included. Examination of this information confirmed that there was regular input from these professionals and details of treatment being provided were recorded. Discussion with staff demonstrated that they were aware of treatment being provided to individuals. Care plan notes for one resident show that staff have carried out blood sugar monitoring for this person. It was discussed with the manager and she was able to confirm that only staff that have completed training provided by the district nurse undertake this procedure. The District Nurse retains ultimate responsibility for this procedure. Discussion with staff demonstrated that they had an good understanding of individual needs of service users and how they could support them with mental health issues and where and when additional support should be accessed e.g. G.P. or Community Psychiatric Nurse for additional advice. Another new introduction to the system is the detail of medicines that the individual takes, the conditions that the medication is used for, how it is administered and the possible side effects it may cause. Assessments are also in place for all areas of daily activity including mobility, bathing, nutrition and pressure area care. These assessments were seen to have been evaluated on a monthly basis or as needs changed, providing staff with up to date information about each individual,s care. Evaluations also included details of what changes had been made to reflect and accommodate the individuals changes in need. Service users have completed a menu preference sheet, which provides information about their individual likes and dislikes and any cultural dietary or special dietary needs e.g. vegetarian, diabetic diets. It also includes information about their preferred beverages throughout the day and details of food allergies. Information is also included about peoples preferred time of retiring to bed and rising. Copies of information from reviews held with Social Services, was also available in care plans including details of any changes that had been made as a result of the review. The homes Quality Assurance Survey responses show that residents and relatives are satisfied with the medical input they receive and information in the care plans. They are also confident that the staff share information about any changes in their relatives health and well being with them. The home uses a local pharmacy Moss Chemist as their medication supplier and has a ‘blister pack’ system of medication, plus some boxes and bottles where medication is not suitable for putting into the heat-sealed system. These medicines are recorded on a separate sheet and signed for by two staff members. Only the senior staff and the manager are involved in the Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 13 administration of medicines and have completed the appropriate training to enable them to do this. Training records confirmed this. Checks of the medication records showed that overall these are well maintained and kept up to date. Observation of the staff showed they are patient and kind with the residents and there is obvious trust between individuals. Verbal communication is not always possible for some residents, but staff work hard to determine what individuals want and try hard to use gestures and facial expressions to make themselves understood. Wyton Abbey DS0000019777.V355384.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 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are provided with opportunities to participate in group social activities. However, age appropriate, individual and diverse needs are not catered for, to meet more individual needs. EVIDENCE: Discussion with people using the service indicated that they were reasonably satisfied with the activities that were on offer in the home and that there was plenty to do which suited most people. Details of activities were displayed on the notice board, along with forthcoming events. Activities included: film afternoons, pampering sessions, manicures, skittles, visits from the music man, bingo and card making. Photographs of the regular outings are displayed throughout the home, service users have given consent to their photographs being used and copies of this are maintained in individual care files. People spoken with were looking forward to the Christmas period and celebrations, in particular a pantomime that had been organised for them. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 15 There is also a hairdressing room where people can have their hair done by a visiting hairdresser. An existng meember of staff has been apppointed as the activities coordinator who will have responsibility for developing the activity programme further. Presently they have not been given additional hours to facilitate this, but complete this within their current allocated hours. The manager and the coordinator are looking into what activities can be offered to the people with dementia in order to meet their needs in this area. They have sought independent advice regarding this and are currently waiting for the information. Individual care plans detailed what activities people had participated in and whether or not they had enjoyed it. Activities also a regular topic on the resident,s meeting agenda, both in relation to people,s experience of activities and suggestions for new activities to be introduced into the activity programme. Relatives made positive comments about the home in the organisation’s Quality Assurance responses, one person said ‘Whenever mum comes to our home, after an hour she is asking to go back to Wyton,’ ‘ The staff are great and nothing is too much trouble for them,’‘It is reassuring to see that the staff are happy and that there is a low staff turnover.’ ‘It is more like a home environment now,’ ‘The staff keep us in touch through phone calls and chats during our daily visits.’ Visitors observed in the home were made welcome by staff and time was made available to them to assist them with their enquiries and provide an update of information regarding their relative. Relatives and service users spoken with said that they were always made welcome, were involved in their relative’s care and were encouraged to join in events in the home. They were always offered refreshments and had open access to staff and could visit at any time. Information from the residents’ files indicates that there are a number of individuals who follow different spiritual faiths, including Methodist, Catholic and Church of England. The Catholic priest visits monthly and there are church visitors who come in and help the residents celebrate the major Christian festivals such as Easter and Christmas. The home encourages residents to bring in small items of furniture and personal possessions to decorate their bedrooms. Discussion with the staff showed that residents with dementia are not aware of their care plans, but families and residents can talk to the staff about their care whenever needed. Discussion with the manager and staff indicated that some residents have their meals in their own bedrooms or the lounges, as they prefer this. Comments from the residents indicated that the food is good, and they are offered choices of meals on a daily basis. Staff are aware of each person’s likes and dislikes and were seen to offer assistance to residents who need help eating and drinking. Specialist plates and eating equipment are available to those who need them and information relating to this was available on individuals’ care plans. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 16 Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 17 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 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The understanding of the arrangements for protecting residents from harm is satisfactory, so overall residents are protected from the possible risk of harm or abuse. EVIDENCE: The home’s complaints policy and procedure was on display throughout the home in written format. People living in the home said that they were able to raise any concerns they had with the manager and felt that they would be listened to. The manager has also set aside specific time on a weekly basis where she makes herself available to service users and relatives to raise or discuss any concerns or issues, details of this are displayed in the home. Although this has proved to be successful with some people living in the home and relatives, some people living in the home may have difficulty in relating to this, the responsible person must consider how the home can provide individuals with a simple and clear complaints policy that is visible within the home and which is available in formats that they can understand. Complaints could also be raised as a regular item for discussion at residents, meetings or on an individual basis with key workers. Additional support could also be Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 18 provided by making details of local advocacy agencies available to both service users and relatives available. There is a complaints book, which is kept locked away in the managers office and information within it shows that no complaints have been reported and investigated since the last inspection. It is recommended that the responsible person considers using a complaints form that is readily available to staff and people using the service at times when the manager is not in the office. Staff spoken with had a good understanding of the complaints process and their role in this. The training files show that the staff and the manager have recently attended further training in safeguarding. Safeguarding issues have been reported appropriately to Social Services and the Commission for Social Care and Inspection since the last inspection. Discussion with staff demonstrated a good understanding of their role in the referral of safeguarding, one staff member had been involved in making a referral in the manager’s absence and had completed this process appropriately informing all parties as necessary. The staff team have also attended training in Dementia, which has included information about safeguarding, dealing with aggression and the medicines used in the treatment of dementia. A staff member has also been appointed as a mentor in the home for the training and to support all newly appointed staff with this. Staff spoken with said that they had benefited from the training and that it had provided them with a greater insight and understanding of the condition. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of cleanliness is not consisitent throughout the home so the experience of people living in the home is varied, some experience a basic environment while others are provided with a warm, safe and comfortable place to live. EVIDENCE: There are two parts to the home: the main home accommodates up to 30 residents and a smaller unit for 3 more independent residents that is separate from the main building, called Garden Cottage. Garden Cottage Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 20 This area of the home has three single en – suite rooms along a main corridor leading onto a lounge/kitchen area. Residents can make snack meals in this area, but those spoken to prefer to eat their meals with the rest of the residents in the main building. Wyton Abbey Wyton Abbey is a large house set back from the main road, in its own grounds, adjacent to the village of Wyton, in the East Riding of Yorkshire. The house is a listed building, has extensive grounds with a small walled garden area for service users to sit in and a large car park for approximately 10 cars. Access to public transport is from the adjacent main road, which is a short walk along the homes driveway. The home provides accommodation on three floors and there is a passenger lift stairs to all levels. There has been some further refurbishment completed through an ongoing programme of routine maintenance to refurbish a number of areas within the home. However there are some areas that continue to need to be addressed. There is loose plaster surrounding the doorframe to the staff room, some carpets were stained and smelled unpleasant and were in need of a thorough deep clean. These carpets have only been recently replaced. Similarly some of the soft furnishings in the lounge areas, which are of a good quality, also smelled unpleasant. The domestic staffing levels in the home need to be given further consideration to ensure that there are adequate hours available to ensure that all necessary tasks are completed including the cleaning of carpets and soft furnishings are maintained to provide people living in the home with a clean and odour free environment. However comments form relatives confirmed that they felt that overall the environment was improving. The home has two mechanical sluices, but discussion with the manager and staff indicate that these have been out of action for a long time. Staff are having to hand wash the commode pans and this creates a risk of ‘splash back’ into their eyes. A requirement was made in respect of this at the previous site visit in June. Although requests made for repairs have been requested and detailed in the maintenance book, the manager was still unaware as to when this work would be completed. These repairs or replacement of the sluices must be completed as a matter of urgency to ensure hygiene and infection control is maintained and staff’s health is protected. The flooring to the ground floor is a polished surface that is discoloured and marked. The manager showed the inspector areas where she has done work to remove the layers of old polish and clean the surface. It was noted that some residents do not like walking on the corridor floor as it is patterned with dark squares and lines across the doorways. People with dementia may perceive these areas as gaps in the floor and this would make them very nervous about moving through the doorways and along the corridors. Although progress has been made with this, there is still considerable work to be done to complete this. Rather than the manager spend some of her time Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 21 removing this, the organisation should consider how the remainder could be removed quickly, to improve the environment. Feedback from staff surveys returned indicated that the downstairs bathroom causes them moving and handling problems when giving residents care, as they feel the room is very cramped. This was also raised at the previous site visit. The responsible individual should look at ways in which this can be addressed promptly to ensure that the safety of staff and service users is maintained. Both parties need to be protected from the risk of injury. Information given to the inspector and observation indicates that some attention is needed to the central heating system within the home. At the previous site visit there were concerns raised about the heating system, this has now been addressed so that the heating can be turned off in the summer if needed, but hot water still be available in the home. Comments from the residents show that overall the home is clean and they are satisfied with the laundry service provided. Wyton Abbey DS0000019777.V355384.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have their needs met by a trained staff group, who are recruited appropriately. EVIDENCE: Currently care is provided to the people living in the home from 4/5 care staff on duty in a morning shift, 4 care staff in the afternoon and 2 care staff at night. The manager’s hours are supernumerary to these figures. In addition to this there are 22.5 laundry hours, 52.25 catering hours and 46 domestic hours. The domestic staffing levels in the home need to be given further consideration to ensure that there are adequate hours available in the to ensure that all necessary tasks are completed including the cleaning of carpets and soft furnishings.(see comments re environment) Comments from the staff and residents indicate that the home is extremely busy at times and individuals may wait for attention at peak times, but the friendly attitude of the staff and their wiliness to help make up for this. A new induction process has been introduced for employees, which has been produced by the company. Copies of these were seen and had been completed and dated with new starters. 60 of staff have achieved an NVQ 2 or 3 and the remaining staff are registered to complete the training. Checks of two staff Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 23 files showed that the appropriate checks had been completed and satisfactory references obtained prior to the person starting employment in the home. Staff training files indicate there is a basic safe working practice training programme in place. Checks of the staff training files and information from the training matrix suggest that the majority of staff are up to date with fire, moving and handling and food hygiene. Since the previous inspection the staff team have attended training on dementia, management of challenging behaviour, medication and protection of vulnerable adults. Health and safety training was also planned for the next week. Staff spoken with demonstrated a good understanding of individual needs, and were able to give clear examples of managing behaviours positively, promoting individual choice and maintaining dignity. Individual files were seen that demonstrate the staff receive formal supervision on a 4 – 6 weekly basis, an annual appraisal and have the opportunity to attend monthly staff meetings. Wyton Abbey DS0000019777.V355384.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36, and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is developing the skills, knowledge and experience to run the home effectively and protect the health, safety and welfare of the residents EVIDENCE: The manager has now been registered with the CSCI. She receives regular visits from her line manager and formal supervision, which is recorded. The manager has attended training on dementia, dealing with aggression, protection of vulnerable adults and drugs used in the treatment of dementia. She has also completed the National Vocational Qualification at level 4 and is half way through the Registered Managers Award. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 25 Since the last site visit the manager has begun to complete regular audits and monitoring systems in relation to the organisational Quality Assurance system. Comments from these audits were very positive and included: staff moral is a lot better and the working environment a lot happier,’ ‘The new manager is fair, understands, we can talk to her whenever we want, staff are ably led by Kim, who is settling in well as manager and always makes sure that all visitors, friends and relatives are well received and acted upon.’ ‘ Kim’s motto is this is your relative’s home now and everyone must feel at home when they visit. Staff and residents meetings are held on a monthly basis and minutes of these are recorded. Further input from the residents about the service is gathered during the manager’s daily walks around the building and chats with the people living in the home. Weekly meetings have also been introduced so that relatives and service users have open access to the manager. Information provided by the company indicates that the home has completed an Annual Development Plan based on feedback from the people using the service and reflecting the aims and outcomes for the residents. Discussion with the manager indicates that she is starting to carry out supervision with the staff and has completed two appraisals. However, she said that she had received no training in these areas and it is unclear what her knowledge base is to be able to do these efficiently and effectively. Information supplied by the company in October 2007 shows that 3 members of staff have not received supervision since April 2007. The responsible individual must make sure the manager receives training and support around the supervision/appraisal process for the staff and receives the same support for herself. In the last two reports (January 2007 and June 2007) a requirement was made that ‘The Registered Person must give notice to the Commission without delay of all untoward occurrences as per the regulations’. This has been appropriately complied with by the home since the last visit. Safeguarding issues have also been reported to the Safeguarding of Adults Team and the CSCI by the manager and the staff team, where a situation arose in her absence. Checks of the accident book found that incidents are recorded. Maintenance certificates are in place and up to date for the utilities and equipment within the building, but there are some areas of the environment and equipment that need attention (see standards 19, 22, 25 and 26). Staff have undergone further training including; medication, dementia and challenging behaviour. Further dates and a letter from the training department, identified further training having been booked in health and safety and infection control. Risk assessments are available for the environment and a copy of the home,s fire risk assessment was also available. Staff spoken with were aware of the risk assessment process and their role within the safe management of risk. Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X 2 X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 3 Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement The responsible person must make sure the manager of the home receives support and training in doing needs assessments, so that she is able to develop further skills in this area and be confident that the home can meet the individuals’ needs. Ongoing from 11/0/07 The responsible person must make sure residents psychiatric and psychological needs are monitored regularly and preventative or restorative care is provided. Ongoing from 11/06/07 The responsible person must ensure the range of activities on offer for people using the service is individualised to meet age, mobility, disabilities and individual needs. Ongoing from 11/06/07 The responsible individual must ensure that disability equipment and environmental adaptations, required to meet the need of the DS0000019777.V355384.R01.S.doc Timescale for action 31/01/08 2. OP8 13(1) (b) 31/01/08 3. OP12 16(2) (m)(n) 31/01/08 4. OP22 23(2) ( c) (n) 31/01/08 Wyton Abbey Version 5.2 Page 28 residents are in place. This needs to be considered in particular to the downstairs bathroom which staff find difficult to accommodate because of the limited space available. Staff and residents’ health and safety need to be maintained and protected from risk of injury. 5. OP16 22 (1)-(6) Ongoing from 11/06/07 The responsible person must 28/02/08 consider how the home can provide individuals with a simple and clear complaints policy that is visible within the home and which is available in formats that they can understand. Ongoing from 11/06/07 31/01/08 The responsible person must make sure that the environment of the home is accessible, safe and suitable to meet the residents’ individual and collective needs. Arrangements should be made for the prompt removal of all of the polish to the downstairs flooring,so that the flooring is more acceptable to service users who have Dementia.. Ongoing from 11/06/07 The responsible person must 31/12/07 make adequate arrangements to ensure hygiene and infection control is maintained and staff’s health is protected. Ongoing from 11/06/07 The registered person must ensure that the home is free from offensive odours. 31/12/07 6. OP19 23(1)(2) (a)(n)(o) 7. OP26 13(3) and 16(2)(j) 8. OP26 13,16 23(d) 23(k) 9. OP27 The registered person must 31/01/08 ensure that the home has an effective domestic team, with sufficient numbers to maintain the provision of in depth cleaning DS0000019777.V355384.R01.S.doc Version 5.2 Page 29 Wyton Abbey 10. OP19 23,2(b) 11. OP19 23, 2 (b) within the home, over and above the daily cleaning routines that are met. The provider must ensure that a plan of routine maintenance is made available to the home manager with specific agreed timescales for the completion of all work reported to the maintenance department. The registered person must ensure that the loose plaster to the surrounding of the door of the staff room is repaired and redecorated. 31/01/08 31/12/07 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. 4. Refer to Standard OP14 Good Practice Recommendations The manager should find out about local advocacy service contacts and put their names and addresses into the Service User Guide The responsible person should consider using a complaints form that is readily available to staff and people using the service at times when the manager is not in the office. Care plan information should be transferred onto the new system. A cleaning schedule should be developed to ensure that thorough deep cleaning of carpets and soft furnishings is completed on a refular basis as required. OP16 OP7 OP25 Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyton Abbey DS0000019777.V355384.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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