Inspection on 22/10/07 for Wyvern Lodge - WSM

This inspection was carried out on 22nd October 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

Wyvern Lodge - WSM 03/12/08

Wyvern Lodge - WSM 14/04/08

Wyvern Lodge - WSM 20/12/06

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 Odette Coveney Key Unannounced Inspection 22nd October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wyvern Lodge - WSM DS0000055608.V345104.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.V345104.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 01934 413388 wyvern_lodge.wsm@virgin.net Mr Brian Edwin Johnson Mrs Pauline Ann Johnson Mrs Carol Ferguson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Wyvern Lodge - WSM DS0000055608.V345104.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. 15th November 2006 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 ground floor wing at the rear. The home has a passenger lift. There is a small, secluded garden with seating to the rear of the home. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standard inspection was carried out in one day over a 7hour period by one inspector for the Commission. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Registered Provider a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for three individuals were reviewed. The registration certificate for the home was reviewed at this inspection and the information contained within it was found to be accurate. A number of comment cards were received prior to the inspection, eleven of these were from relatives of those who live at the home, two from individual’s who live at the home, and two comment cards were from visiting health/social care professionals who visit individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. What the service does well: What has improved since the last inspection? Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 6 Requirements made at the last visit to the home were that the home must only admit those people whose needs fall within the categories for which it is registered. No concerns were noted at this inspection in respect of those individuals admitted into the home and those living at the home appear to have been appropriately placed. It was noted during the last site visit to the home that there were records that were missing or have not been completed such as: • • • • • Pre-admission assessments. Medication records regarding residents who self-medicate. And 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. All of the above documentation was reviewed and was found to be in place, to be well ordered and contain all of the required information. Details of which can be found within the main body of this report. The roles of the manager and responsible individual have now been formally clarified and are clearly documented. What they could do better: In order that residents can feel confident that staff are aware of their needs it has been required that care plans and mobility handling profiles must be reviewed and updated in order that they reflect individuals changing needs. It was further recommended that care plan agreements are signed by residents and all residents’ files be put in order for a consistent and ordered approach. In order that resident’s wishes about their end of life choices are respected it is recommended that the home seek methods of gathering and recording this information. In order that resident’s medication is clearly accounted for it is required that controlled medication must correspond with medication records held at the home. In order that the residents live in a clean, hygienic and safe environment a number of requirements in respect of these areas were made, please see the main body of the report. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 7 In order that residents are supported safely it is essential that staff have the amount and type of training required specifically in areas of adult protection and fire safety. In order that residents identity is verified it is required that photographs of all residents are in place at the home. 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. Wyvern Lodge - WSM DS0000055608.V345104.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.V345104.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, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information in place about the facilities and services provided at the home is good. Individuals living at the home can be confident that their needs will be met. EVIDENCE: The Home’s Statement of Purpose has detailed information about services and facilities provided at the Home. This document is available to the prospective resident or their representative when they visit the home to enable them to make an informed choice of moving to the home A requirement was made during the last site visit to the home that a written pre-admission assessment must be carried out and a copy kept on site and furthermore that the manager must write to confirm that the home will be able to offer a service on the strength of the information acquired and only people whose needs fall within the homes registered categories may be admitted. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 10 A review of care documentation found that the manager of the home does complete a pre-admission questionnaire with the prospective resident, that covers areas such as; personal care support, previous medical history, medication, social and cultural support needs. Copies of completed assessments were seen on file. It was also noted that the manager writes to residents in order to formally offer them a placement at the home confirming their room and date of admission. During this site visit following discussion with the manager, registered provider, residents and a review of documentation and observation of those living at Wyvern Lodge no concerns were noted in respect of those living at the home. Those living at the home appeared to be appropriately placed. Intermediate care is not provided at this home. Wyvern Lodge - WSM DS0000055608.V345104.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, 10, 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are able to access healthcare services and all individuals have a care plan in place, however improvements must be made to information contained within care plans and controlled medication must be better recorded. EVIDENCE: Three individuals care records were reviewed at this inspection and it was found that the plans in place had been generated from a care management assessment. Information contained within care records included: an individual’s profile containing information about the reason for admission, health care support services involved, next of kin, family contact details and medical history. Each resident also had a pre-admission assessment form completed by a care manager, risk assessments, records of health professionals visiting, daily records of individuals routines and a care plan. The home reviews resident’s care plans on a monthly basis and changes had been recorded, however individuals changed needs had not always been reflected within individuals care plans. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 12 It is required that residents care plans must fully reflect the changing needs of residents, furthermore it is recommended that care plan agreements are signed by the resident, where they are able and residents’ files should be ordered and tidy as it was noted that not all files were consistently ordered. Thorough examination of care documentation evidenced that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. Procedures for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monitored dosage system. A check of the blister packs indicated that controlled medication had not administered as recorded and it is required that this must be improved in order to protect residents. All medication seen was stored securely. The pharmacy supplies printed medicines administration record sheets each month. A number of concerns were noted at the last site visit of the service in respect of medication administration and recording processes at the home. Requirements were made that medication administration records must show when residents are self-medicating also that 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 and also that controlled drugs must be stored in line with current guidance. All of these areas were reviewed during this visit and for those individuals who self medicate records were clear and this was being monitored appropriately by the home. No concerns were noted about the storage of controlled medication. Comments received from relatives of those who live at the home via ‘Have your say about the service’; included: ‘ the home is friendly, the food is good, people are given a choice, very happy with the care provided’ other comments were; ‘its like one big, happy family’. Two comment cards were received from health and social professionals prior to the inspection these all said that the home the home communicates clearly and works in partnership with them, that staff demonstrate a clear understanding of the care needs of service users and that they are satisfied with the overall care provided to residents at the home It was noted that information was in place to demonstrate that resident’s wishes concerning terminal care and arrangements after death have been discussed. However not all residents wishes were recorded. It was recommended that the home seek ways of obtaining and recording the views of residents in the event of their death in order to ensure that individual’s wishes are respected. Wyvern Lodge - WSM DS0000055608.V345104.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. 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. Residents can keep close contact with relatives,friends and the community. Residents are offered a varied and nutritious diet, and are able to take part in a range of social activities. EVIDENCE: Information seen evidenced that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. On the day of the visit residents were playing board games with a staff member and told of their enjoyment of this. Discussion with the manager, staff members and evidence from the visitors’ book showed that the residents maintain good contact with families and representatives. The level of contact varies for each resident living at the home, some receive regular visitors and go out with family, and others do not. It was evident from interactions between staff and residents during the inspection that staff have developed positive relationships with the residents. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 14 The home would contact individual’s next of kin should they need to be informed of issues, which affect the well being of an individual living at the home. At a brief walk around the building residents were seen spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. The inspector observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made after consultation on the meals available to them. Of the comment cards received from residents prior to the inspection no negative comments were made about meals at the home. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of residents from harm and abuse, however not all staff have received training in this area and this must be undertaken. EVIDENCE: The home has appropriate procedures in place for management of complaints. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the home. Resident’s responses noted on the comment cards evidenced that residents are aware of whom to complain to, no concerns from residents or their representatives were raised on these comment cards. The home maintains a record of complaints and the last recorded complaint was some time ago, however it was dealt with effectively and the parties involved were satisfied with the response from the home. The inspector spot checked money being held at the home for three residents. Records and receipts in place corresponded with money being held for safekeeping. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 16 The home has clear adult protection protocols in place and discussion with the registered provider further evidenced his understanding of this area, furthermore discussions evidenced that the provider would act in the best interests of residents if an allegation were made, however, although some staff have received adult protection training, not all staff have, see staffing section of this report. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 17 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, 21, 22, 25, 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is safe and the quality of furnishings are of a good standard and suitable for the needs of residents, however some improvements are required with the cleanliness of the home EVIDENCE: Wyvern Lodge is a residential care home for older people located within a residential area of Weston Super Mare, both male and female residents live at the home. The home is close to local amenities and public transport. There is a spacious dining area and a comfortable lounge area with comfortable furnishings; there is car parking to the front of the house and a garden for residents use to the rear of the home. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 18 A brief tour of the building found the home to be comfortable with an array of soft furnishings which made the environment very homely. The home was found to be dirty in some areas, bathrooms on the first and ground floor were in need of a clean and areas within the dining room were in need of dusting, in order that a clean, hygienic environment is provided for residents it is required that cleanliness within the home must be improved. It was required during the last site visit to the service that the carpet on the bottom step of the second flight of stairs needs to be made safe, this was no longer an area of concern as the whole of the stair carpet and landing areas had new carpet fitted, enhancing the area for those who live at the home. There are adaptations in place throughout the home with specialist equipment including mobility aid, sensory aids, and specially adapted baths. It was noted that the handrail on the bath in the second floor bathroom was rusted and potentially dangerous, it is required that this handrail be replaced. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. Toilets are situated in readily accessible parts of the home near to communal areas and bedrooms. There is a spacious kitchen in the home. It was observed that there were a number of areas of hygiene concern, which included the following: • • • • • Insecutter full of dead insects; this must be cleaned. Build up of dirt and grease on top of kitchen cupboards, under the kitchen sink and behind the cooker, food debris on the kitchen floor. Cobwebs from the ceiling, these areas must be cleaned The window fan was thick with dirt and grease, this must be cleaned. There was no soap, products for cleaning hands must be provided. Requirements in respect of improving these areas were made during this site visit. Attention must be given to the identified en suite bathroom floor in order that it is safe as it was noted that previous flooring had been taken up leaving the flooring underneath and the edging to the bedroom carpet unsafe with the potential for the resident to trip. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29. 30. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Safe recruitment and selection practices are in place at the home. Some staff have received training, however staff must undertake specific training in order to ensure the safety and protection of residents. EVIDENCE: There is a well-established staff team at Wyvern Lodge. During the inspection staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. The home has a structured induction programme. This is to ensure that new staff members are competent and confident to work with residents to meet their needs. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 20 A requirement was first made on 20/07/05, and was subsequently reviewed at follow up site visits to the service that staff must not work in the home until all pre-employment checks have been satisfactorily completed and the evidence filed in the home. A review of the most recently appointed staff member was undertaken and the appropriate employment checks had been undertaken. It was recommended during the last site visit to the service that the rota should make it clear which member of staff is in charge of each shift. Another requirement made during the last site visit to the home was that a copy of the duty roster and a record of whether it was actually worked must be kept in the home. The rota was viewed and there was clear information to show who was responsible for the shift, rotas were being maintained and information was in place to demonstrate who worked each shift. It was noted at the last site visit that a clear written agreement is needed on the division of responsibilities between the manager and the responsible individual and also that the manager needs to have the time and the resources to properly fulfil the demands of her role. Discussions took place with both the responsible individuals and the manager separately. Both confirmed that arrangements suited the home. Supervision records were seen which showed that these areas had been discussed with allocation of duties being agreed and recorded. It was noted that there had also been a slight increase of the managers weekly hours and this will again be reviewed at the next site visit to ensure the manager has the time to fulfil her role. A requirement was made at the last site to the home that staff must have training in abuse awareness, basic food hygiene, first aid, manual handling and fire instruction. Discussion with the manger, a review of staff files and training records found that although some training has been undertaken not all staff have undertaken training in abuse and fire instruction, fire instruction for all staff had not been undertaken for a year, this is unsafe and puts people at risk, attention to these areas must be undertaken as a matter of priority. It was recommended at the last site visit to the service that the manager should undertake a further manual-handling course at the earliest opportunity, and staff should receive yearly refresher training in manual handling. Records and confirmation from the manager evidence that this training had been undertaken. Comments made by residents during the visit and comments given by relatives of those who live at the home prior to the visit included; ‘ all of the staff are very nice and pleasant’, ‘I find the owners and manager and staff are very helpful and kind and are always willing to listen to us, ‘I am quite contented and comfortable at Wyvern Lodge’ Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 21 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, 35, 36, 37,38, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is run by persons who are able to discharge their responsibilities fully. Although the home appears to be run in the best interests of residents there were a number of concerns in respect of health and safety. EVIDENCE: Mr and Mrs Johnson are the registered providers of the home. Mrs Carol Ferguson is the registered manager. Mrs Ferguson has been the manager of the home for some time and has completed a National Vocational Qualification at level four in care management. Mrs Ferguson demonstrated a sound understanding of her role and responsibilities and had a clear knowledge of the needs and wishes of those living at the home. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 22 There was some evidence that the home ensures so far as is reasonably practicable. the health and safety of resident’s staff and visitors, but this must be improved. The home has robust policies and procedures in relation to aspects of health and safety. However it was noted that residents’ manual handling assessments had not all been fully completed and some were outdated and did not reflect information seen in care records. In order to ensure the safety of both residents and staff it is required that mobility and handling profiles must be reviewed and updated. Furthermore concerns were raised when it was noted that chemicals hazardous to health were not being stored safely within the home. It is required that the home must adhere to COSHH (control of substances hazardous to health) legislation in respect of safe storage. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipment and recording of training and testing of equipments were satisfactory, as noted in the staffing section of this report staff are not receiving sufficient fire instruction and this could put themselves and residents at risk. A requirement was made during the last site visit to the home that the fire risk assessment needs to be revised in line with the new fire regulations. The risk assessment in place had been well completed, was in depth and covered all required areas. In order to validate individual’s identity, photographs of all residents must be in place, there were no photographs in individual’s care records and not all were found on individuals’ medication records. Residents’ meetings are held regularly at the home and minutes on the notice board showed that individuals are asked their opinion about the running of the home and how the service can be improved for those who live there. Wyvern Lodge - WSM DS0000055608.V345104.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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X 18 3 2 3 3 2 X X 3 1 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 24 Yes 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 OP7 Regulation 15 (2) b Requirement Residents care plans must fully reflect the changing needs of residents. Mobility and handling profiles must be reviewed and updated. Cleanliness within the home must be improved. Cleanliness within the kitchen must be improved. Controlled drugs must be accounted for in line with current guidance. The kitchen fan and the insectucutter within the kitchen must be cleaned. Handrail in the bathroom on the second floor must be replaced. Timescale for action 23/11/07 2. 3. 4. 5. OP38 OP26 OP26 OP9 13 (5) 16 (2) j 16 (2) j 17, Sch. 3 23/11/07 23/11/07 23/12/07 23/10/07 6. OP26 16 (2) j 23/11/07 7. 8. OP22 OP30 23 (2) c 18 23/11/07 Staff must have training in abuse 23/03/08 awareness and fire instruction. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 25 9. OP38 13 (4) a Substances potentially hazardous to health must be stored in line with COSHH regulations. 23/11/07 10 OP19 16 (2) c Attention must be given to the 23/12/07 identified en suite bathroom floor in order that it is safe for residents. In order to validate individual’s identity photographs of all residents must be in place. 23/12/07 11. OP37 17 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 OP7 OP7 OP31 OP11 Good Practice Recommendations The resident must sign care plan agreements where they are able. Residents care file to be tidied and put in order. The managers hours should be kept under review. The home should seek and record individual’s wishes for in the event of their death. Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Wyvern Lodge - WSM DS0000055608.V345104.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!