Care Home: Wolborough Court Nursing Home

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What the care home does well The home operates an admissions process which ensures that people are only admitted after their needs have been assessed. People are able to visit the home as part of the admissions process and this enables them to make an informed choice about whether they want to live in the home. The home offers those who live there a varied diet and is responsive to their individual likes, dislikes and needs relating to food. People who live at the home have access to a variety of stimulating activities. Relatives and friends of those who live in the home are made welcome, encouraged to visit and to join in activities and events within the home. Wolborough Court is a newly built home which has a high standard of hygiene and cleanliness and which meets the needs of those who reside there. What has improved since the last inspection? This is Wolborough Court`s first inspection since it was registered. What the care home could do better: The manager should continue training for the NVQ 4 and Registered Manager`s Award so that she has the recommended qualifications for someone responsible for running a nursing/care home. CARE HOMES FOR OLDER PEOPLE Wolborough Court Nursing Home 32A College Road Newton Abbot Devon TQ12 1EQ Lead Inspector Andy Towse Key Unannounced Inspection 9:30 5 and 6th December 2007 th 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 Wolborough Court Nursing Home DS0000070297.V352729.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. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wolborough Court Nursing Home Address 32A College Road Newton Abbot Devon TQ12 1EQ 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) 01626 355191 NB - RIs home address is logged under former addresses Mrs Nicola Jayne Rogers Mr Guy Perring Rogers, Ms Michelle Ann Stepney Mrs Nicola Jayne Rogers Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22), Physical disability (22) of places Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Physical disability (Code PD) Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 22. First Inspection 2. Date of last inspection Brief Description of the Service: Wolborough Court is a purpose built nursing home. It shares the same campus as St. Benets, a home owned by the same directors. The property has been built to fit in with other Georgian type properties in this residential area. The home is registered for up to 22 older adults, all of whom are accommodated in single occupancy bedrooms with ensuite facilities. The property is spacious, well equipped for those who reside there, with all new furnishings and décor. The fees charged at Wolborough Court range from £492 to £610. Personal purchases such as newspapers, hair dressing and chiropody are not included in these fees. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is 2 star. This means that the people who use this service experience a good quality outcome. This was the first inspection of this home since it opened in July 2007. The inspection was unannounced. Information prior to the inspection was obtained through surveys, which were forwarded to people who live at the home, healthcare professionals and staff. This information was complimented by additional information supplied by the registered manager in the form of an Annual Quality Assurance Appraisal (AQAA). The inspection itself comprised a visit to the home and a tour of the premises. We examined records within the home, including care plans of three of the people who reside there. We spoke with five people who live at the home and two visitors. We also spoke with the manager, who is also one of the owners, another director, two nursing staff, a member of the care team and the cook. The following report reflects the findings of this inspection. What the service does well: What has improved since the last inspection? Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 6 This is Wolborough Court’s first inspection since it was registered. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 7 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 Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. People who live in the home benefit from an admissions process which allows the home to assess whether it can meet their needs before deciding whether it is appropriate to admit them. People also benefit from being able to look around the home as part of the admissions process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three people who live at Wolborough Court were case tracked as well as discussions with the manager, staff, relatives and the people themselves. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 9 One of the directors explained the home’s admission process, and during the course of the inspection there was an emergency admission to the home. This admission involved healthcare professionals faxing relevant information about the person, such as mobility, tissue viability, nutrition, sleep pattern and communication, to the home. Other information kept on file, by professionals, and used in the community was also to be forwarded. This information would enable the home to have considerable knowledge about the person and assist them in deciding whether the home could meet their needs. In addition to what was observed during the inspection, one of the directors explained that it was usual practice for her or the registered manager to visit prospective residents in their home or hospital as part of the admissions process. Some files examined were seen to contain Pre-Admission Forms which would support these comments, although these forms were not always dated. Files also contained assessment forms completed by relevant healthcare professionals which would assist those at the home in charge of the admissions process in determining whether the home could meet the needs of prospective new residents. Another person was admitted from Wolborough Court’s sister home, St Benets. This meant, with the involvement of the directors with both homes, that there was prior knowledge of this person’s needs before she was admitted to Wolborough Court. This person’s file contained a health needs assessment including details of the person’s mobility, medical history, continence and tissue viability. There was also information, in the form of an assessment, which had been compiled during the person’s stay in a hospital rehabilitation unit. A further file contained very detailed information supplied by that person’s family, together with an assessment compiled by the home on the person’s day of admission. One visitor confirmed that when looking for a home they had visited several homes, all of which they had visited unannounced and the result was that they had chosen this one. In conversation, one person said that she had chosen the room she currently occupied and confirmed that her family had visited several homes choosing this one as being suitable to meet her needs. The home does not offer intermediate care. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. People who live in the home benefit from regularly reviewed care plans People have regular access the healthcare professionals. Medication procedures are safe. The privacy and dignity of those who live at the home is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people who live at Wolborough Court have care plans. The care plans and files of three people were inspected. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 11 Care Plans were seen to be reviewed regularly. These reviews showed that action was taken to meet the changing needs of the people concerned. Examples of this were the installation of a mattress to reduce the possibility of pressure sores, encouraging fluid intake and the carrying out of exercises, the latter having been recommended by a physiotherapist. Some care plans contained recommendations made by healthcare professionals such as physiotherapists and speech therapists. Records confirmed that in most cases recommendations made in the care plans were carried out. Entries on care plans and records showed that people had contact with healthcare professionals, in accordance with their needs and as recommended in their care plans. All files contained risk assessments which covered moving and handling, their environment, susceptibility to pressure sore and nutritional needs. These were reviewed and amended in accordance with the changing needs of those to whom they referred. The home has policies relating to the administration and storage of medication. Medication is only administered by trained nurses. Medication was seen to be stored securely in a locked trolley which was secured to the wall. Controlled drugs are kept in a locked box within the cabinet, which is also secured to the wall. At the time of the inspection there were two sets of medication stored in the controlled drugs cabinet. Inspection of the controlled drugs record book showed that on each occasion when controlled drugs were administered there were two signatories and a record of remaining stock taken. There was a signed record of all medication which had been destroyed. Some medication which had been brought in by a person living at the home but was now not being prescribed, was dated July 2007 and had yet to be destroyed. Whilst this medication should have been destroyed there was no other medication which was out of date. On one of the days of the inspection it was seen that the director checked medication upon its arrival in the home. On this occasion she found a discrepancy between what she had been informed was the medication dosage and that which was written on the medication label. In the interest of the person’s welfare this was checked with the general practitioner and the Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 12 appropriate dosage confirmed by fax prior to the medication being administered. The process of administering medication was discussed with one of the staff responsible for its administration and records regarding the administration of medication were seen to be appropriately maintained. In discussion, one person said that staff always watched to see that she had taken her medication. Those who live at the home were spoken to about the care they received. They all confirmed that they were treated with dignity and that their privacy was respected. This was confirmed in discussion with a member of staff who gave good examples of how they ensured the privacy of people. Examples given, being knocking on bedroom doors before entering, allowing them to take more responsibility, if they are able, regarding their personal care and making sure curtains are drawn. Staff were seen to knock on bedroom doors before opening them and to speak with people living at the home in a courteous and respectful manner. Wolborough Court Nursing Home DS0000070297.V352729.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 and 15 Quality in this outcome area is good. Those who live at Wolborough Court or offered the opportunity to participate in various different social activities. Wolborough Court encourages visitors, both to visit their relatives and to participate in functions and meetings at the home. Those living at the home have a varied diet which meets their needs. The registered manager has put into place training to ensure that all staff have the necessary training relating to the preparation of food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examples of activities for the month of December showed that there was plenty happening at Wolborough Court. This was mainly concerned with Christmas events as would be expected, but did show involvement with the local community with various different groups doing carol singing at the home. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 14 There were also activities such as sing-a-longs, and on one day of the inspection, a drama group who put on a fast moving and energetic interpretation of Hansel and Gretel. This involved some audience participation and in later discussion those who were present said that they had enjoyed it. Discussion with one of the directors and some records showed that previously there have been events like clothes shows and novelty occasions such as a special menu, complete with menu card for a Halloween meal. In addition to events at the home, there are also shared events with Wolborough Court’s sister home, St Benets. The home also commissions an ‘activities lady’ who spends two hours twice a week at the home encouraging people to get involved in activities which have included, floor dominoes, arts and crafts, skittles and chair based activities such as target map, exercises and basket ball. During the inspection we spoke with two visitors. Both confirmed that they could visit at any reasonable time and were made welcome. We saw a staff member offering visitors refreshments, which we were told was usual practice. Relatives are also invited to attend functions at the home and were seen to be present watching the theatrical production on the day of the inspection. Information on the notice board shows that residents meetings are scheduled to commence from the beginning of 2008. Relatives involvement in the home was shown by the notices which invited them attend these meetings. Those who live at Wolborough Court are encouraged to bring with them personal possessions of their choosing. One person was proudly showing what they had brought, which included a bed, some furnishings, numerous pictures, plants and a television. Others had telephones installed in their rooms. The home operates a four-week menu. This shows that those who live at Wolborough Court have a varied diet and that there is a choice at every meal time. Adjacent to the kitchen there is a preparation room which can be used by staff to prepare snacks and beverages for people whilst not disrupting any work going on in the kitchen. Notices in this room referred to certain people’s likes and dislikes regarding food and also instruction regarding the preparation of foodstuffs for others, often in accordance with what was stated on their care plans. The cook presented as enthusiastic about her work, and has started her own quality assurance system by recording on a kardex system the likes and dislikes of each resident. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 15 As stated previously the menu was varied and there was seen to be ample amounts of fresh vegetables in the kitchen on the day of the inspection. The meal time was observed. Those eating were relaxed, eating in a dining room which is well furnished with the advantage of adjoining doors meaning that it can be extended into the adjacent dining area or kept as a smaller room, dependent on the number of residents or function occurring. Those who were spoken to were generally satisfied or very satisfied with the food available. Those who require pureed food had it presented in an appropriate manner with each constituent pureed separately and in a later conversation with one of the directors we were told that the home was considering introducing moulds to enable the pureed food to be reshaped in order that it would look more appetising. Records were seen to be kept of all food prepared and its temperature. At the time of the inspection, whilst the cook presented as competent and enthusiastic, discussion revealed that she had not obtained her basic food hygiene qualification. This was brought to the attention of the registered manager who contacted the Commission for Social Care Inspection (CSCI) the following day to inform us that the cook would be attending this training within the week and that rotas would be altered to ensure that only those who had the food hygiene qualification would be working in the kitchen until the cook resumed work after receiving the necessary training. Some staff already have had training relating to basic food hygiene, however training for staff who do not have this training has been arranged for 4th. January 2008. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Those living in the home are protected by a written complaints procedure, and staff who are knowledgeable about what constitutes abuse and what to do if they suspect that it is occurring. People were confident in approaching the management of the home if they wanted to raise issues or complain. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a written complaints procedure. This is made available to those who live at the home and their relatives. In discussion those spoken to who live at the home and a visitor, all confirmed that should they have any complaints or concerns they would feel confident in approaching the registered manager or any member of staff. One spoke about being aware of the home’s policy of not allowing staff to accept gifts. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 17 Staff spoken to were conversant in what they considered to be abuse and what action they would take if they thought that it was occurring. This was also confirmed in the responses received from staff to the pre inspection survey when they replied that they ‘knew what to do if a service user/relative/advocate or friend had concerns about the home.’ The home has a revolving programme of training. This includes all mandatory training including that relating to the protection of vulnerable adults (POVA) and abuse. It is required that within six months of appointment staff have received training relating to the protection of vulnerable adults. Training schedules made available show that POVA training was held on 9th. October 2007 within four months of the home opening. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. Wolborough Court offers those who live there a clean, spacious environment which meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Wolborough Court is a new and purpose built home for older adults although it’s façade is that of a Georgian property and it looks indistinguishable from other residential properties in this residential area. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 19 The premises are totally new as are all furnishings, except those chosen by people moving into the home who have the right to bring in their own furniture. There is a very high standard of hygiene and cleanliness. All bedrooms have an ensuite facility and many have very good views and even those at the rear of the property have in many cases an outlook onto an area which has been made into a garden. All rooms have specialist profile beds to lessen the possibility of pressure sores. There are ample bathing facilities which as well as assisted bathrooms also include two wet rooms which make assisting those with complex needs to wash, easier and more effective. There are two rooms which will contain macerators, one is in situ; the other is on order. These are situated separate from bathing and washing facilities. The dining room has an ‘over flow’ room adjacent which means that it can accommodate differing numbers of people depending upon need or event. The laundry room was seen to be clean and light with waterproof flooring and washable walls to ensure good hygiene. Bathrooms and toilets had paper towels and soap dispensers to promote hygiene and reduce the risk of infection. Bedrooms were seen to have been personalised by their occupants. Two spoken to were pleased to show what items they had brought from their previous place of residence. All bedrooms had lockable doors and there were items of lockable furniture. Rooms were numbered but also had signage in the forms of pictures of various animals to assist people in recognising which room was theirs. The home has two lounges, the larger having the capacity to accommodate all those for whom the home is registered, which makes it a good venue for functions, such as the play which was being performed on the day of the inspection. All areas of the home can be accessed by use of a passenger lift. Externally the home has a level patio affording good views and which is easily accessible for those who live at the home. One of the directors spoke of putting a gate to the top of the stairs leading down from the patio to ensure the safety of people using it. Those spoken to told of choosing their rooms. They also were pleased about the layout of their rooms. All rooms had alarm pull cords, which were accessible to the rooms’ occupants. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Those who reside at Wolborough Court receive care from an appropriately trained staff group, in numbers sufficient to meet their needs. People who reside at Wolborough Court are protected by the home’s recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rotas were made available. These showed that on every shift there was, in charge, a trained nurse. In the morning between 8am and 2pm there were four care staff and one nurse and from 2pm until 8pm there were two care staff and one nurse on duty. At night times there are two wakeful staff, one of whom is a trained nurse. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 21 Staff spoken to considered that the staffing levels were appropriate to meet the needs of those who live there and were ‘safe.’ Discussion with one of the directors and the registered manager confirmed that staffing levels would rise in accordance with increasing numbers of people living in the home or changes in the assessed needs of those who lived there. The home has a commitment to training. It has a revolving programme of training which includes moving and handling, fire safety, and the protection of vulnerable adults and abuse, and following discussion at this inspection, basic food hygiene. This training is carried out every six to eight weeks, depending upon staff training needs, by a trainer employed by the Court Group of homes. Staff are paid to attend training. The files of four staff were examined. These showed that all staff working at the home had had police checks and the home was in receipt of two good references confirming their suitability to work with vulnerable people. The file of a staff member from abroad was also examined. This contained official confirmation that this person was regarded to be of good character in their country of origin. This person’s nursing qualifications were seen to have been validated for work in this country. New staff participate on a formal induction process. This includes 4 hours spent with a senior staff member who goes around the home with the person, introducing them to people who live in the home, and discussing policies and procedures. Thereafter the staff member will commence work, shadowing more experienced staff but also participating in the Skills For Care, ‘Working Towards Better Standards’ induction process. Workbooks completed by staff and a manual was made available. These showed that during formal induction staff were made aware of the home’s policies and procedures, legislation such as that affecting dangerous substances (C.O.S.H.H.) and Health and Safety, through to the role and responsibility of a care worker, working with and responding to unpredictable behaviour and understanding challenging behaviour. In discussion, aspects of more recent legislation were discussed, and the registered manager was able to show information produced by the Court Group relating to the Mental Capacity Act and how it will affect those in receipt of care and those responsible for providing it. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. The registered manager should acquire the accepted qualifications expected of a person registered to carry on a nursing home. Those who live at the home have their financial interests protected by the home’s policies and procedures. The home has already commenced a Quality Assurance system, which seeks to obtain the views off those who have used the service. Staff supervision has commenced for some, although not all staff. The health, safety and welfare of those who live at the home is protected by the home’s policies and practices. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 23 This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is run by a registered manager. She has yet to complete the training and attain the qualifications expected of someone running a nursing home. Whilst she is not a qualified nurse, nurse related responsibilities are the responsibility of nursing staff, one of whom takes responsibility for every shift. The registered manager was not present during the first day of the inspection, but was present for the second day. Rotas were made available to show that she had worked regularly at the home since it was opened. Another director was present on both days of the inspection. Although she did not appear on the rota she said that she was at the home most days, and in discussion and from observation she did appear to play an important role in the running of the home. This was observed from her checking incoming medication, liaising with healthcare professionals about a forthcoming admission, arranging training and activities within the home, and generally being knowledgeable about the running of the home. It was discussed that the hours worked at the home by this director should be recorded to show the managerial input available. The home opened in July 2007. Since that time surveys have been sent out to people who have used the service. To date five responses have been received. The Quality Assurance Surveys contain questions about whether people living at the home had received enough information prior to moving in, how did they rate the atmosphere in the home and the attitude of staff, how did they regard the cleanliness of the home, the overall care. They were also asked whether there was anything that could have been provided which would have enhanced their stay and any concerns they had during their stay. Overall the responses were very positive. There was however one response which referred to someone’s rooms not appearing to have been ‘cleaned on a regular basis’. This was discussed with a director who considered that it related to when the home first opened and care staff were carrying out domestic duties as well as their care duties. We discussed staff supervision when examining staff files. Four staff files were examined. All contained signed supervision contracts. These stated that the member of staff would receive six supervision sessions per year. Examination of the files showed that one person had received formal, recorded supervision. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 24 This had been recorded on a formatted template containing information on topics such as complaints and protection, personal care and health and environment. There was specific emphasis regarding personal care with the agreed action being that this staff member attended a course on death and dying and increased their knowledge about nutrition. In discussion it was agreed that supervision should take place six times a year, but that did not necessarily mean every two months. In discussion a staff member said that they considered themselves ‘supported’ by the home’s management and that the management was approachable. Wherever possible those living at the home, or their relatives on their behalf, are encouraged to manage their own finances. Where this is not possible and the home has to look after money on behalf of people who live in the home there were seen to be appropriate procedures in place. These included the safe keeping of the money, limited staff access to it and appropriate records of expenditure including the retention of receipts. The registered manager confirmed in the Annual Quality Assurance Assessment (AQAA) which she forwarded to the Commission for Social Care Inspection (CSCI) prior to the inspection, that the home had the necessary policies and procedures in place to ensure the safety of those who either live or work in the home. The information supplied also states that the home will have ‘electrical testing on all appliances annually’ and that the gas central heating system will be ‘serviced annually’ with a ‘health and safety inspection of the building and grounds carried out monthly.’ The home has a fire risk assessment which was carried out by the staff member who has specific responsibility for this and staff training. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations That the registered manager continues training for NVQ 4 and the Registered Manager’s Award, which are the qualifications expected of a person running a nursing or care home. Wolborough Court Nursing Home DS0000070297.V352729.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 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 Wolborough Court Nursing Home DS0000070297.V352729.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. 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