Inspection on 20/12/06 for Wyvern Lodge - WSM

This inspection was carried out on 20th December 2006.

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

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

Other inspections for this house

Wyvern Lodge - WSM 03/12/08

Wyvern Lodge - WSM 14/04/08

Wyvern Lodge - WSM 22/10/07

Wyvern Lodge - WSM 09/03/06

Wyvern Lodge - WSM 20/07/05

Wyvern Lodge - WSM 01/12/04

Wyvern Lodge - WSM 16/08/04

Wyvern Lodge - WSM 23/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wyvern Lodge - WSM 154 Milton Road Weston Super Mare North Somerset BS23 2UZ Lead Inspector Catherine Hill Unannounced Inspection 15th November 2006 01:35 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 Wyvern Lodge - WSM DS0000055608.V312592.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. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wyvern Lodge - WSM Address 154 Milton Road Weston Super Mare North Somerset BS23 2UZ 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) 01934 413388 NONE Mr Brian Edwin Johnson Mrs Pauline Ann Johnson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person under 65 years for respite care. This condition is specific to one person and will lapse when the person reaches 65 or leaves the home. Date of last inspection Brief Description of the Service: Wyvern Lodge is registered for up to 16 older people. It is situated in a residential area, near accessible local amenities. The bus stop to the town centre and sea front is just outside the home. Wyvern Lodge provides day care for up to 5 people each day. Most of the accommodation is in the original part of the building but some rooms are in a new ground floor wing at the rear. The home has a passenger lift. There is a small, secluded garden with seating. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two visits, approximately 5 weeks apart. The first visit was made just before Christmas and was almost entirely given over to talking with the residents. The second visit was made in late January and involved looking at how responsibilities are allocated, and at systems and records in use in the home. CSCI comment cards were also sent to a number of external care professionals associated with the home. Two responses were received, and these indicated that these professionals have confidence in the quality of care. As part of this unannounced inspection, the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Other documents looked at during this inspection included: • Residents’ contracts • Service User Guide • Pre-admission assessments • Activities • Medication records • Menus • Complaints • Abuse procedure • Fire precautions testing and training • Fire Risk Assessment • Residents’ care records • Staff rotas • Staff recruitment, training, and supervision Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home must only admit those people whose needs fall within the categories for which it is registered. Some records are missing or have not been completed: • Pre-admission assessments could not be found for a couple of residents. • Medication records need some improvements regarding residents who self-medicate. Any handwritten entries on these records need to be signed by two staff. Controlled drugs need to be stored in line with good practice guidance. • Rotas that have already been worked need to be kept on site, and these need to clearly show who worked when. • Recruitment records for existing staff need to be completed. • The Fire Risk Assessment needs to be revised in the light of the new fire regulations. Staff need to have the amount and type of training required. The roles of the manager and responsible individual have still not been formally clarified. As a result, there are some aspects of the running of the home that they are both actively working on, and other aspects that neither person is addressing. This is starting to have a negative impact on residents well-being and safety. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 7 Fire precautions equipment checks need to be carried out with the required frequency. 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. Wyvern Lodge - WSM DS0000055608.V312592.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 Wyvern Lodge - WSM DS0000055608.V312592.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is adequate. Residents get good information about the home before they decide to move in, but the home is not always able to show that a proper pre-admission assessment has been done on the person. Contracts are very clear, but the local authority contract would be improved by including the room number. EVIDENCE: The inspector asked three of the residents about the information they had received before moving into the home, about their contracts, about what happens when their fee levels change, and about how their needs were assessed before they moved in. This was as part of the thematic probe mentioned in the summary of this report. None of these people could actually remember seeing the Service User Guide, but a resident sitting nearby helped to explain what it is and where copies can be found. A copy of the Service User Guide is kept in each bedroom. Two vacant bedrooms had been prepared for the next occupant and a copy of the latest Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 10 version of the Service User Guide had been placed in them. This guide is kept under regular review and updated as necessary. It is in a very easy to read format, and includes the views of existing residents. On the first day of this inspection, residents’ contracts were not available as the responsible individual was keeping them at his own home. He brought these into the home the same day, and confirms that they are now being kept on site. There are two versions of the contract for each resident: one covers the homes expectation of the individual, and the other covers what the home promises to provide. Each of these is very clear, straightforward, and reasonable. The homes own contracts specify a room number. Local authority contracts include a note of the allocated room but some of these simply say yes rather than specifying the room number. The inspector suggested that the home enters the room number if the placing social worker has not. The minimum fee level is £336.65 and the maximum is £405. The Responsible Individual writes to placement funders in advance of any fee increase. The manager usually asks for the placing social workers care plan prior to doing her own assessment: if it seems likely that the home will be able to offer the person a service, the manager then visits to carry out her own assessment. A couple of assessments were missing from residents files, but the manager confirmed that these had been done. It was not possible to confirm whether these had been informal assessments or whether they had been written down. The home does not write to the agent requesting the placement to confirm that it will be able to offer a service if that agent is a local authority. The home is registered to admit people who fall within the Older People category only. While some newly admitted people may have very mild confusion, with which the staff team is well equipped to cope, no-one with more significant dementia or mental health needs may be admitted. People with a history of alcohol abuse may not be admitted to homes that do not have the A category. It is the registered manager of a home who is responsible for deciding on placements. The home does not provide intermediate care. Wyvern Lodge - WSM DS0000055608.V312592.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. Residents care needs are well documented. Medication records are generally good but need more detail in some regards. Controlled drug storage needs to comply with current guidance. EVIDENCE: Care plans and associated documentation are excellent, giving really clear information on each aspect of the persons life, and helping to promote good and consistent practice among the staff team. All of this documentation is being reviewed every month, and any updates are clearly noted. Residents are fully involved in drawing up their care plans and agreeing how their needs will be met. A good range of risk assessments is in place for each person. Most of those sampled indicate low risk. Where a higher level of risk is identified, the assessments included the actions to be taken to reduce the risk to an acceptable level. Medication records were generally very clear. Photographs of the residents are kept at the front of this file, and the record sheets are colour-coded. There Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 12 were no unexplained gaps in these records. Medications received into the home had been properly recorded. Some residents retain responsibility for self-medicating, perhaps only in respect of a cream but occasionally with stronger medicines, but this had not been clearly noted on the Medications Administration Records. Written risk assessments need to be drawn up in respect of those people who selfmedicate, and a formal system needs to be set up to monitor the continued success of this. Controlled drugs must be kept in a locked cupboard that is secured within a locked cupboard, which in turn is secured. The supplying pharmacist may be able to advise on suitable arrangements. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 13 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. The home has a lively atmosphere, with plenty of interest going on. Visitors are not just made welcome, but fully involved in the homes life. The quality of meals is good. EVIDENCE: A varied schedule of regular activities is offered, including board games, keep fit, and trips out. Residents were really pleased with the range of activities and outings, especially as these are all provided free of charge. Residents said that their visitors are always made welcome, and are often included in the homes social life. Residents rights and responsibilities are recognized in their daily lives at the home. Residents comments supported observations during this inspection: that staff treat them with respect and warmth. People are offered choices wherever possible, care is given flexibly, and residents dignity is promoted. Menus are interesting and balanced, and likely to suit older peoples needs and tastes. Residents were highly satisfied with all aspects of the meals. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. Residents are clear about how to complain and feel confident that any concerns would be taken seriously. Written guidance to staff on reporting abuse is exceptionally clear, but many staff have not had abuse awareness training. EVIDENCE: No complaints have been received by the home or by CSCI. The Service Users Guide - a copy of which is placed in each bedroom - includes the complaint procedure and policy. This is very clear and straightforward, and includes CSCI’s contact details. None of the residents involved in the thematic probe could remember seeing a written copy of the homes complaints procedure, but each of them was confident that staff would listen to anything that was worrying them. The home has an excellent abuse procedure, which gives really clear guidance and useful examples, and also reminds staff of their legal duties. It is suggested that this policy is signed and dated on any review. Abuse awareness training has been provided to some staff over the past year, and more training is planned for the future. However, many staff have not had abuse awareness training for the past few years, and a dozen staff training records indicated that they had not had this training at all. Residents said that any issues are always addressed promptly, and staff are very open to their comments. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 15 Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26 Quality in this outcome area is good. Residents benefit from a pleasant environment that is well suited to their needs. EVIDENCE: The whole home has been redecorated since the new owners bought the business a couple of years ago. The inspector only looked at the communal areas during the current inspection, but residents told her how happy they are with their rooms. Communal areas are all decorated and furnished to a good standard. There is a small patio garden at the back of the home. The bottom step on the second flight of stairs has a frayed hole in the carpet that could be a trip hazard. This needs to be made safe. All bedrooms are over 10 m square. Thirteen bedrooms are single, two of which have an ensuite, and one is a double with ensuite. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 17 There are two adjoining lounges, and the dining room leads of one of these rooms. These rooms are all comfortable and light. There are five communal toilets and three bathrooms. All areas of the home seen during these unannounced visits were clean and fresh-smelling. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Quality in this outcome area is adequate. Staff recruitment practice has improved but the gaps in existing staffs records have not yet been filled. Although some staff training has been provided, not all staff have had the required amount and type. EVIDENCE: Only the past two weeks rotas were available in the home. The responsible individual said that he keeps old rotas at his own house in order to work on staff wages. All the documents listed in Schedule 4 of the Care Standards Act 2000 must be kept on site. The rotas seen show only one member of staff on duty at some times, and indicate that staff below the age of 21 are left in charge of the home. The manager and Responsible Individual assured the inspector that this is not the case, and residents all said that there are sufficient staff on duty at all times. However, the rota of management hours that was recommended at previous inspections is no longer being kept up, so there is no evidence of the hours that the manager and responsible individual are working in the home. In addition to this, there is an apparently uncovered vacancy for a cook three days a week, and vacancies for staff doing evening and sleep-in shifts. The manager said that both of these roles are currently being covered by the responsible individual and his wife, but this is not shown on the rota. A copy Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 19 of the rota and a record or whether it was actually worked must be kept in the home. The manager confirmed that there is always a minimum of two staff on duty day and night, and the rota shows additional staff are employed at peak periods. It was recommended at an earlier inspection that the rota should make it clear who is in charge of each shift, so that staff know who should be undertaking tasks such as calling the emergency services. Following that recommendation, the home drew up a list of which staff have NVQ2 and which have NVQ3, and this was kept with the rota so that staff could check who would undertake the responsible senior role on each shift. That list was not with the rotas, so the recommendation was repeated. It was a requirement at the last two inspections that staff must not work in the home until all pre-employment checks have been satisfactorily completed and the evidence filed in the home. Following the last inspection, the thenmanager amended the employment checklist to ensure that in future this requirement will be met. No new staff have been employed since then. However, no action has been taken to complete the required records for existing staff. A record must be kept of proof of identity, evidence of qualifications, evidence that the person is physically and mentally fit for their role, and evidence that a satisfactory Criminal Record Bureau check has been carried out in respect of each staff member. Copies of references also need to be kept on file. Staff statutory training has slipped over the past year. Little training has been provided, statutory training is not up-to-date in all staff’s cases, and most staff are not receiving the minimum three days paid training per person per year. Only two staff records showed that basic food hygiene training has been provided: none of the general assistants records included this training, and yet they are responsible for some food handling. Over the past 12 months, some staff have had training in subjects such as dementia awareness, abuse awareness, moving and handling, and first aid. However, the responsible individual has been providing the moving and handling training, despite not being qualified as a trainer in this subject. While it may be useful for staff to have general training from experienced managers, specialist training needs to be provided by agencies competent in that area. The home’s manager has not had manual handling training for several years, and yet is responsible for monitoring manual handling practice. Given the level of dependence of some of the residents, it is recommended that the manager undertakes a further manual handling course at the earliest opportunity, and that staff receive yearly refresher training in manual handling. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 38 Quality in this outcome area is adequate. Although both the manager and responsible individual are experienced and qualified, there is no clear allocation of responsibilities, and some key areas of management are being ignored. This is starting to have a negative impact on residents safety and well-being. EVIDENCE: Carol Ferguson has been registered as the manager since the last inspection. Prior to that, she worked at the home as deputy manager. She has held NVQ4 for several years. Both she and the Responsible Individual are experienced in the management of older people’s homes. The manager and Responsible Individual were advised at the time of registration to draw up written definitions of their respective roles to ensure that responsibilities were clear. They confirmed at this inspection that this has not yet been done. There are some jobs that both people are undertaking - for Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 21 example, both people tend to book staff annual leave and plan the rota around this. Other tasks are not being properly monitored by anyone - for example staff training and fire precautions checks. This lack of clarity is allowing for unnecessary duplication of work, and creating room for staff to become confused over which authority to follow. There are also some vital aspects of the home’s management that have been allowed to slide. The situation is exacerbated by the fact that the manager is only working 30 hours a week. At present, she works two 10-hour days and two 5-hour mornings a week. The Responsible Individual does one 10-hour day each week and works 5 hours in the afternoons of the manager’s short days. This provides a good level of overall management cover to the home, but is not currently allowing the manager adequate time to cover tasks such as one-toone staff supervision, planning staff training schedules, assessing potential residents, and overseeing residents care plan reviews. There are some times on the rota when the manager acts as the second member of care staff. This helps her to keep up-to-date with residents needs and the standard of care being offered, but it further reduces the already restricted opportunities for management time. A manager needs time to monitor and reflect upon the service being offered, and to plan service development. It is recommended that the managers hours are kept under review. There was little evidence of quality monitoring. However, a good range of written guidance to staff is already in place, most of which is kept under regular review. The inspector suggested that when one of the two people in the management team needs to temporarily remove a record from the home, they keep a record of the date they removed it and the date it was returned. This will help to ensure that both people know the whereabouts of critical documents. The manager does not have any budgetary responsibility at present. This is not a satisfactory arrangement, given that she is responsible for the management of staffing levels and staff training. Most residents or their relatives retain responsibility for their finances. Where the home looks after small amounts of cash on residents behalf, clear records are kept. Dates for one-to-one supervision showed that all but one of the staff have not been having the required frequency of formal supervision: each staff member should have formal supervision at least six times a year, but most staff supervision sessions were four months apart. The manager has planned the schedule of supervision for the coming year, and two-monthly sessions have already started. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 22 A professional trainer gives the staff team a lecture on fire safety every summer. Homes Fire Risk Assessments should detail the frequency with which staff receive intermediate refresher training; the Fire Officer recommends that this is every six months for staff covering daytime duties and every three months for staff covering night-time duties. The Fire Risk Assessment in its present format is inadequate, and needs to be revised in line with the new fire regulations. Fire precautions equipment testing and fire drills are also not being done with the necessary frequency. Many of the staff first aid certificates are no longer current or are due for renewal in the very near future. The numbers of staff who hold a current first aid certificate are insufficient to guarantee a qualified first aider on duty at all times. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 23 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 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X X 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 3 2 2 2 Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP3 OP4 OP4 Regulation 14 4 & 14 Requirement A written pre-admission assessment must be carried out and a copy kept on site. The manager must write to confirm that the home will be able to offer a service on the strength of the information acquired. Only people whose needs fall within the homes registered categories may be admitted. Medications Administration Records must show when residents are self-medicating. Written risk assessments must be drawn up in respect of those people who self-medicate, and a formal system needs to be set up to monitor the continued success of this. Any handwritten entries on these records need to be signed by two staff. Controlled drugs must be stored in line with current guidance. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 25 Timescale for action 26/01/07 26/01/07 3. OP9 17, Sch. 3 02/02/07 4. OP19 23 5. OP27 17 & 18 6. OP29 19 The frayed hole in the carpet on the bottom step of the second flight of stairs needs to be made safe. A copy of the duty roster and a record of whether it was actually worked must be kept in the home. Staff must not work in the home until all pre-employment checks have been satisfactorily completed and the evidence filed in the home. This requirement was first made on 20/07/05. 02/02/07 26/02/07 23/02/07 7. OP30 18 8. OP31 10 9. OP38 23 Staff must have training in abuse 23/03/07 awareness, basic food hygiene, first aid, manual handling and fire instruction. A clear written agreement is 23/02/07 needed on the division of responsibilities between the manager and the Responsible Individual. The manager needs to have the time and the resources to properly fulfil the demands of her role. The Fire Risk Assessment needs 23/02/07 to be revised in line with the new fire regulations. Staff training and fire precautions checks need to be carried out with the prescribed frequency. 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. Refer to Standard OP27 Good Practice Recommendations The rota should make it clear which member of staff is in DS0000055608.V312592.R01.S.doc Version 5.2 Page 26 Wyvern Lodge - WSM 2. 3. OP30 OP31 charge of each shift. The manager should undertake a further manual handling course at the earliest opportunity, and staff should receive yearly refresher training in manual handling. The managers hours should be kept under review. Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wyvern Lodge - WSM DS0000055608.V312592.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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