Care Home: Wychwood

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What the care home does well The pre-admission assessment of a recently admitted individual was thorough giving the reader a good knowledge of the care required to look after that person adequately. The food the people using the service receive continues to be of a good standard. The expert by experience stayed for lunch and commented that she enjoyed it. The staff team are loyal to the people they care for and decorated the lounge and dining room in order to improve environment for them. What has improved since the last inspection? During the inspection in November 2008 one requirement was made. The service was requested to ensure that the staff rotas accurately reflected the hours that the registered manager was on site in her capacity as registered manager and this has now been met. What the care home could do better: Two requirements were made as a result of this key inspection:The care plans are to be regularly reviewed and updated to ensure they contain all of the necessary and up to date information. People who use the service should receive, where necessary, treatment, advice and other services from the health care professionals. Records of this should be maintained.WychwoodDS0000013845.V378308.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Lesley Garrett Key Unannounced Inspection 3rd November 2009 09:30 DS0000013845.V378308.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Wychwood DS0000013845.V378308.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Wychwood DS0000013845.V378308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wychwood Address Headley Road Hindhead Surrey GU26 6TN 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) 01428 607014 wychgroup@hotmail.com Mrs Mumtaz Minaz Lalani Mrs Mumtaz Minaz Lalani Care Home 24 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0), Physical disability (0) Wychwood DS0000013845.V378308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) Physical disability (PD) The maximum number of service users to be accommodated is 24. 2. Date of last inspection 10th November 2008 Brief Description of the Service: Wychwood care home is registered to provide personal care and accommodation for up to 24 older people. The provider is also the named registered manager. The registered premises comprise of two separate buildings, which are known as Wychwood, which is a detached two- storey building and Wychdale, which is a detached bungalow. There are a total of 18 single and 3 shared bedrooms all with emergency call bells and washbasins. Some have en-suite toilet facilities and others have en-suite showers or bathrooms. Assisted bathrooms and toilets are also available on all floors. Wychwood has a communal lounge and separate dining room and Wychdale has a combined lounge/dining room and domestic style kitchen. Wychwood DS0000013845.V378308.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 service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection of the care home was an unannounced Key Inspection. Mrs. L Garrett, Regulation Inspector, carried out the inspection and was assisted by an expert by experience whose main focus was to speak with people using the service and to look at the environment of the home, Wychwood, and the bungalow Wychdale. We arrived at the service at 09:30 and were in the home for seven hours. It was a thorough look at how well the home is doing. It took into account information provided by the service and any information that CQC has received about the service since the last key inspection in November 2008. The registered manager had supplied us an Annual Quality Assurance Assessment (AQAA) and the information contained within that document will also assist us to make judgments. Surveys were sent to the registered manager who then distributed them to the people who use the service, the staff and health care professionals. The expert by experience spent time talking with some of the people living at the home in order to seek their views about the home and the care they receive. We looked at how well the service was meeting the key national minimum standards and complying with the regulations and has in this report made judgments about the standard of the service. Documents sampled during the inspection included the service’s Statement of Purpose and Service User Guide, care plans, daily records and risk assessments, medication records, staff files, training records and the service’s safeguarding and complaints policies and procedures. From the evidence seen by us and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Wychwood DS0000013845.V378308.R01.S.doc Version 5.2 Page 6 What the service does well: The pre-admission assessment of a recently admitted individual was thorough giving the reader a good knowledge of the care required to look after that person adequately. The food the people using the service receive continues to be of a good standard. The expert by experience stayed for lunch and commented that she enjoyed it. The staff team are loyal to the people they care for and decorated the lounge and dining room in order to improve environment for them. What has improved since the last inspection? What they could do better: Two requirements were made as a result of this key inspection:The care plans are to be regularly reviewed and updated to ensure they contain all of the necessary and up to date information. People who use the service should receive, where necessary, treatment, advice and other services from the health care professionals. Records of this should be maintained. Wychwood DS0000013845.V378308.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 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 Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people who wish to use the service have access to current information about the home, which allows them to make an informed decision about an admission. EVIDENCE: We sampled the service user guide and statement of purpose. Both documents contained information about the home, the staff and the services it provides. Information is also available about fees and details of the services that are not included in these fees. The copy that was available in the staff office was last updated in June 2007. We were then told that this was the wrong copy. We were then shown the correct documents held in the administration office and told that the copies in the staff office would be replaced. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 10 Since the last inspection in November 2008 there has been one admission to the home. The registered manager carried out the pre-admission assessment. This assessment had been typed and placed in the care plan folder. It was detailed and allowed staff to have a good picture of the care that this individual required. The home does not offer intermediate care. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans and risk assessments do not fully reflect the current needs of the people using the service and health care professional visits were not recorded in the care plans that were sampled. EVIDENCE: We sampled two individual care plans of people who use the service. These were looked at in detail and discussed with some of the care staff on duty that day. It was observed that care plans and risk assessments were in place for both people but some of the information contained within these documents was incorrect or not fully completed so as to give clear instructions to care staff. One person using the service had been identified during the pre-admission assessment to be regularly physically or verbally aggressive towards staff or other people in the home. A behaviour chart was in place which recorded an Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 12 incident of verbal or physical aggression every day since admission. The risk assessments that were in place for this person did not detail how staff was to manage any incidents that occurred but stated observe and monitor for actions to minimise risks. During the last key inspection in November 2008 it was documented that one person’s file contained evidence of challenging behaviours currently being monitored by staff. The record was not yet complete to demonstrate fully the action being currently taken to address these issues. Staff confirmed that they had not received any training in challenging behaviour. On the day of inspection a member of staff had arrived from an agency who had been employed to look after the individual with the challenging behaviour on a one to one basis. Staff spoken to on the day told us that they were frightened of this particular person and one staff member told us they had been punched and on another occasion grabbed around the neck. The staff member stated that the registered manager was aware of the attack but on the day of inspection we were told that the member of staff only reported this incident recently after they had been hit by the person using the service. A Regulation 37 had been received by the commission for the punch to the face on the staff member. The nutritional risk assessments in place for two individuals were not correct. We spoke with the staff who told us that they had been asked by the person who is the proposed manager of the home to complete the nutritional risk assessments for all people using the service. Staff told us that they had not received any instruction or training in how to complete these assessments so just wrote down what they thought to be correct. One nutritional assessment stated that there was no risk but this assessment had not been scored correctly as the medical diagnosis of this individual had not been taken into account. Lunch time was observed and it was noted that the person this nutritional assessment referred to was reluctant to eat and persisted in pushing the plate of food away. This behaviour upset the person sitting opposite on the dining table who also became agitated and telling staff that if he didn’t want the food she would eat it. It is acknowledged there was a food chart in place to record how much food and drink was taken at each meal time. Another nutritional risk assessment stated normal diet but at lunch time the person whose nutritional assessment this was was observed to be eating a meal which contained liquidised meat. They also required prompting from members of staff to eat; this too was not recorded on the documentation made available to inspectors on the day of the site visit. Following the inspection the registered manager sent us a copy of a document detailing that this individual should have liquidised meat. We spoke to the staff about the individual’s diet during the site visit and we were not told there was a care plan that was kept separate from the information made available to us. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 13 The manager for the service told us that all care plan documentation was in the process of being changed, reviewed and updated. This was also the case during the inspection of November 2008. The person in charge told us that the previous deputy had been responsible for the writing and updating of the care plans. The new manager’s intention was to involve the carers more in this process and as a consequence training in care plan writing was planned. There was concern amongst the staff spoken to during the site visit that they would not have the time to write care plans during what could be busy shifts. In the care plan documentation of the two service users we case tracked we could not evidence that the care plan content had been agreed by them or the next of kin. However, it is acknowledged that in the documentation submitted to the Commission by the registered manager following the site visit there was evidence that care plan agreement could not be obtained from one of the service users whose plan we looked at. The registered manager told us in the AQAA that she had completed a course in End of Life Care Planning. Evidence supplied to the Commission following the site visit showed that the manager was working with families to ensure this element of care wishes was incorporated into the care plans. Evidence obtained during the inspection showed that this was still ‘work in progress’. The expert by experience spoke with one person in the bungalow who told her that she had fallen at a day centre and now felt safer walking with a stick. She told the expert that she had been loaned one by another person but did not know how to obtain one for herself. This person was also concerned about an eye appointment and hoped the new manager would remember that it was in December. The AQAA states ‘We have established an extremely good relationship with our GP’s and other health care professionals’. On the day of inspection we looked at the health care records for both people we case tracked. One person had not been seen by a doctor since January 2008 and the other one had not seen the GP since admission. Both individuals’ care needs had changed. The person in charge told us that people using the service are routinely assessed by the community matron who reports to the GP and will then recommend who the GP visits at the home. We were also told that when people using the service are seen by the matron or district nurse notes are kept. There were no notes for both individuals and no records had been written by staff at the home following any visits that took place to both these residents. The medication administration records (MAR) were sampled for the two people using the service. It was noted that one individual had been refusing the prescribed medication since the 31st October. The MAR stated refused but no reason for the non administration was written on the back of the chart and there had been no review by the GP. Policies and procedures are in place regarding medication which all staff have access to. The person in charge told Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 14 us that the previous deputy was responsible for the ordering and retuning of medication to the pharmacy and another system had not been established yet. In the mean time the person in charge said that she will be doing this. We observed staff knocking on bedroom doors and speaking courteously to individuals. Arrangements are in place for people using the service to receive their visitors and visiting professionals in private. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff on a regular basis provide activities for people who use the service but these remain very limited. A well balanced diet is offered to all people in the service. EVIDENCE: Staff told us that they have created an activity corner in the lounge. Resources were available for the staff and people who use the service that included books, newspapers, crafts, puzzles and reminiscence information. On the day of inspection one member of staff sat at the table with a person using the service assisting with a puzzle. Later the expert by experience observed a member of staff again sitting at the table rolling a ball back and forth to a person using the service. The television was on and newspapers were available. The information board in the dining room told the people that use the service that the activity of the day was television/ music/ newspapers and magazines/ ball games. During the day there were regularly three to four people sitting in the lounge. The person in charge told us that activities are Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 16 currently under review and one to one activities are more acceptable than group activities due to the mental frailty of the people using the service. Staff told us that two members of staff have been identified as activity coordinators as these members of staff have the skills to organise the activities and to motivate the people who use the service to join in. The AQAA told us we provide organised activities to suit our residents and where they are able support them to access and remain a part of the local community. The AQAA also told us that the home has company transport suitable for wheelchair use that can be used for personal or group outings. One person using the service told us that ‘unfortunately trips in the minibus are no longer available’. A representative of a person using the survey completed a survey for us and said under the heading ‘what could the home do better? ‘More daily activities, not a lot of variety during the day’. Staff that completed the survey told us when asked what could the home do better? ‘more use of local amenities’, ‘use the home’s mini bus and car for outings’, ‘to encourage residents to attend local activities/events’. One person in Wychdale told the expert by experience that she was very lonely and wanted people to talk to. The expert by experience observed that the staff that were available were unable to facilitate interesting activities or even conversations and communications taking place as a part of daily life. They told the expert usually there is one member of staff in the bungalow and they have to up date and complete care plans along with their care tasks. On the day of inspection there were no visitors to the home although the person in charge stated there are no restrictions to visiting times. A local vicar visits the home every month to give communion for those people using the service that request this. Catering arrangements are well organised. The chef works in the home six days a week and a relief cook is employed on his day off. He is aware of the food preferences of people using services and of any dietary needs. The menu is displayed on the wall in the hall outside the dining room in Wychwood. The day’s menu is written on an orientation board in the dining room that also has other information about the date, day and weather. The menu is also available in the dining room in Wychdale. The expert by experience joined the people using the service for lunch in Wychdale which she enjoyed. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are generally protected by the safeguarding procedures but these need to be reviewed and the information available and the style of training need to be updated. EVIDENCE: The complaints log was observed and this showed that no complaints have been received by the home since the last key inspection in November 2008. The home’s complaints procedure is included in the service users guide file and all people who use the service have access to this document. The complaints folder was observed and currently the home has a list of all historical complaints. The folder should contain the original complaint letter and the investigation details and follow up letters to the complainant. A discussion took place with the person in charge who will ensure this takes place if the home receives any further complaints. Records indicated that the home has had one safeguarding referral during the past year and one that is in progress. The home has the local authority’s safeguarding procedures 2008. The copy kept in the staff office in the home was the 2005 copy. This copy should be Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 18 removed and replaced with the copy from the administration office. Staff records sampled demonstrated that training had taken place in safeguarding procedures. Staff told us that most training is with a DVD but this does not allow them to have any questions answered as there is not usually a facilitator. Staff that were spoken to on the day however were clear about their responsibilities and who they would contact in the event of suspecting an incident of abuse. Following the site visit the registered manager provided information that she attended update training on safeguarding that took place on the 25th November 2009. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in a clean home and will benefit from the proposed refurbishment of the home. EVIDENCE: During the previous inspection in November 2008 we were told that the buildings works had not started as planning permission had not been obtained. During this inspection we were told that planning permission has now been granted but work is yet to commence. Staff told us that they had decorated the lounge and dining room in white to brighten these areas up. They also told us that they had done some planting in the garden to make the area more attractive for people using the service now that the fencing had been removed. The garden had not been fully accessible Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 20 during the last inspection as the builders had erected metal fencing around the home in preparation for the building work to begin. Then expert by experience toured the home and Wychdale. It was observed that in the bedrooms of the people who use the service there was a lack of personal items. In general it was noticed that there were no photographs and only some small ornaments; there was no sense of ‘home’ in them. The AQAA told us that people who use the service live in a safe and well maintained home that is homely, clean, hygienic and pleasant. The manager employs one housekeeper who takes pride in maintaining the home to a good standard. On the day of inspection it was noted that on the first floor of the main building there was a strong smell of urine and cigarette smoke. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers at the home on the day of inspection were sufficient to meet the assessed needs of the people using the service. National Vocational Qualification training for the care staff continues to ensure a good skill mix of staff on duty. EVIDENCE: The staffing rotas were sampled during the day. It showed us that there are usually five members of staff on during the morning and four during the afternoon. Three members of staff work at night to cover the bungalow and main house. On the day of inspection there were only ten people using the service in the main building and four in the bungalow. One person was proving to be a challenge for the staff but an agency carer had been arranged to look after this person on a one to one basis. Staff spoken to on the day told us that they tried to cover any gaps in the rota to avoid the use of agency staff. On the day of inspection there was a senior carer in charge until the newly appointed manager arrived at 10:15. The rota also indicated the person who was on call for that day. NVQ training is available for staff at the home. On the day of inspection the people in charge were unclear about how many staff actually had the Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 22 qualification but the AQAA stated that 62 of staff had achieved this qualification at either level 2 or 3. Three staff employment folders of the most recently recruited members of staff were sampled and were found to have the necessary paper work to enable the home to employ those people safely. This ensures that the people who use the service are protected by the home’s recruitment procedures. All staff that returned our surveys told us that the management had carried out the necessary checks prior to them being employed. We were shown the training schedule for the home. This identifies the training that has taken place that year and the training that is planned for the staff. Training included moving and handling, safeguarding adults, infection control, person centred care, end of life care, skin care and COSHH. Staff told us that training usually consisted of a DVD but this gave no opportunity for staff to ask questions. We were told by the manager prior to our inspection that the person who was formerly the deputy manager of the home will be doing a lot of the training for staff in the future. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements at the home have changed since the previous inspection and practices within the service still need to be imbedded to improve the quality of life for the people using the service. EVIDENCE: On the day of inspection a senior carer was in charge in the morning until the newly appointed manager arrived. We were told that the former deputy manager left in June this year and the newly appointed manager started work on the 2nd October. We were told it is the intention of the current registered manager to step down and to register the current person who is now in charge on a daily basis. We were assisted with this inspection by the newly appointed Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 24 manager and the owner’s husband as the registered manager was not available. The newly appointed manager told us that she has experience of running care homes and has previously been a registered manager. The owner is currently the registered manager who has run the home now for a number of years with the assistance of a deputy manager. The care planning arrangements at the home and the documentation kept for each person using the service are in the process of being altered. The newly appointed manager told us that some documentation had changed but the process had not been completed. Documentation was also being adjusted last year which was observed during our last inspection. We consider that the records in the service need to be improved to ensure that the health and wellbeing of individuals is promoted. Information available to staff and other professionals needs to record individual needs and what action has been taken by staff and other professionals so this can be referred to and appropriate action taken when required. The registered manager decided to send a completed AQAA to us in June 2009 before we had requested the document. It was sent on a CSCI template and the commission did not ask for a further AQAA to be completed. The manager had not updated this document so the information contained within is still current. Records showed that every month a meeting is organised for the people using the service and their relatives or representatives. For the last two months no one has attended. The home has produced a newsletter in May and August 2009 with another planned for December. The home sent out surveys to seek the views of the people using the service in October 2009. The home does not hold any allowances for the residents on the premises. The organisation does hold a deposit of £100.00 to meet any out of pocket expenses when people leave the home. The AQAA told us that all necessary health and safety certificates were in place. During the inspection the expert by experience observed the maintenance man going into the loft in the bungalow to retrieve some supplies. In order for the maintenance person to obtain supplies from the loft in the bungalow he had to climb a ladder, reach and pull him into the loft leaving the ladder unattended. He then had to reach down to the ladder again to descend with the goods required. Since the site visit the manager has informed the Commission that failure to have another member of staff at the foot of the ladder while it was in use was an oversight. Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 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 2 X 3 X X 3 Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? No 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 Requirement Care plans to be regularly reviewed and updated to ensure they contain all of the necessary and up to date information. People who use the service should receive where necessary treatment, advice and other services from the health care professionals and ensure the documentation is available. Timescale for action 18/12/09 2. OP8 13 18/12/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wychwood DS0000013845.V378308.R01.S.doc Version 5.3 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southeast@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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