Inspection on 11/07/06 for Godwyne Hurst

This inspection was carried out on 11th July 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Godwyne Hurst 18/06/08

Godwyne Hurst 20/06/07

Godwyne Hurst 19/01/06

Godwyne Hurst 13/07/05

Godwyne Hurst 16/11/04

Godwyne Hurst 07/06/04

Godwyne Hurst 10/05/04

Godwyne Hurst 21/10/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Godwyne Hurst 2 Leyburne Road Dover Kent CT16 1SN Lead Inspector Chris Randall Unannounced Inspection 11th July 2006 10:10 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 Godwyne Hurst DS0000023200.V301793.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. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Godwyne Hurst Address 2 Leyburne Road Dover Kent CT16 1SN 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) 01304 206391 Mrs Doris Anne Hodgson Mrs Doris Anne Hodgson Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Godwyne Hurst is registered to provide residential care for four service users over the age of 65. The property is a large building, which also contains rooms for independent private tenants on the upper two floors separate from the residential home. There is a shaft lift to enable service users with mobility difficulties to access the two floors of the registered residential part of the building. Service users all have single bedrooms. There are two small lounges and a dining room with adjoining kitchen that service users are able to use communally. The home is located within the town of Dover with local amenities close by. Godwyne Hurst is owned and managed by Mrs Hodgson. The home is mainly family run with three members of staff (one of whom is Mrs Hodgsons son) working flexibly. The current fees for the service at the time of the visit range from £270 per week to £270 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The home does not have an e-mail address. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The homes pre-inspection questionnaire and comment cards from Service users were taken into account. During the site visit the inspector spoke to the manager, the two service users, and two staff members. Interactions between staff and residents were observed, and various records were examined. What the service does well: What has improved since the last inspection? What they could do better: The front entrance to the home needs a lot of work to make it look more welcoming. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 6 Daily records in service users care plans need to be completed on a daily basis, and the care plans must be reviewed with the service users monthly. A copy of the homes complaints procedure should be displayed in the home to ensure service users, and visitors can easily see how to make a complaint if they wish to. Improvements are needed regarding staffing, including the keeping of staff files, updating the homes induction package, 50 of staff to be trained to NVQ Level 2 or above, staff to undertake statutory training, and regular staff supervisions to take place. The manager should do her NVQ Level 4 in Management and Care. She should also introduce a formal quality monitoring system and documented development plan for 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. Godwyne Hurst DS0000023200.V301793.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 Godwyne Hurst DS0000023200.V301793.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have sufficient information and can be satisfied the home will assess and be confident of meeting their needs prior to their admission. EVIDENCE: Questionnaires received back from both service users confirm they had enough information about the home before moving in and that they have received a contract. A contract was also viewed on one of their files. Although the two current service users have lived in the home for many years, the manager does have a comprehensive pre-assessment planning tool ready to use for any new prospective service user. Joint assessments would also be obtained for any service user who was care managed. The home are very clear that they will not accept new service users unless they are sure that they can meet their assessed needs. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 9 The home does not offer the service of intermediate care Godwyne Hurst DS0000023200.V301793.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their health care and medication needs will be met and that they will be treated with respect. EVIDENCE: The home has produced a care plan for each service user. These care plans are individualised to meet their assessed needs and include various assessments and risk assessments. Although there is a daily record sheet this is not currently being completed daily as more detailed information is being written in the communication book, which is not appropriate. Care plans are reviewed informally but no structured review takes place and there is no documentary evidence. When asked if they were involved in the monthly review of their care plans one service user commented, “they ask what we want and don’t want”. A requirement has been made that a daily record must be maintained in the Care Plan and that Care Plans should be reviewed with Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 11 the service user on a monthly basis. The monthly reviews must be documented and the service user should sign to indicate their approval. The staff, supported by various health care professionals, are meeting Service users health care needs. Evidence was seen of appointments with various health care professionals. Both service users indicated on the questionnaires sent out by CSCI that they always receive the medical support they need. When asked whether the care and support they needed was met one service user commented, “Yes, quite well”. Only one of the service users is on regular medication and this is self administered under supervision. The recording of medication received, given and disposed of is appropriate. The home does not have a specific drugs fridge but are currently following the advice of Boots pharmacist and are storing fridge line drugs in a locked bag in a separate compartment at the bottom of the homes fridge. The manager normally oversees medication. Staff have been waiting to undertake medication training but the training provider has cancelled this 3 times in the last 18 months. One service user confirmed that privacy and dignity are upheld, and this was observed during the course of the inspection. There is a friendly family atmosphere in the home, but interactions between staff and service users are nevertheless respectful. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live as part of the providers family. They are supported in activities that suit their individual needs; have choices in all aspects of daily life; and have nutritious and wholesome meals. EVIDENCE: With a current occupation of only two service users, the home is run very much as a family home. Activities tend to be more individualised which suits the service users. There are occasional trips out together, with a trip to see the band planned. Service users commented, “I read a lot, watch T.V., go out on my scooter occasionally, and do my jigsaws, I don’t want any other activities”, and “ I do anything I can that I can manage, I like to do my tapestry”. Neither of the service users have many visitors but family do write, send cards or phone occasionally. The family of the owner often visit and her mother lives Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 13 on the premises. One service user commented, “I like seeing the children”. If visitors do come to see the Service users they can sit in the second lounge, their bedroom or the garden if they require some privacy. Service users have choices and made comments of, “we get a reasonable choice, time of getting up and going to bed, what to wear, what to do, I choose to walk down the stairs rather than use the lift”, “I can choose what I want to do”, and “we can make choices but whether they go through or not depends” The home does have a four week set menu, and meal choices are discussed with service uses. However the set menu is not always adhered to because it is often changed if the service users want different things. Sometimes they choose to have take away meals, pizza, fish & chips or MacDonald’s just for a change. The meal served on the day of the inspection looked appetising and was well presented. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure needs to be on display to ensure that service users and their visitors know how to make a complaint if necessary. Service users are generally protected from abuse. EVIDENCE: Although the home has a complaints procedure a copy of this was not on display on the day of the inspection for easy reference of service users and visitors. A requirement is made that the complaints procedure should be prominently displayed in the home. There have been no complaints registered since the last inspection and service users confirmed that they had no complaints but would know how to make one if it were necessary. The home has a copy of the Kent and Medway Adult Protection protocols and staff know where to access this. Although not all staff have received Adult Protection training one staff member confirmed that she knew about Adult Protection and about the homes whistleblowing policy. She commented, “I would definitely report abuse, even if it were the manager”. All staff have had an Enhanced Disclosure from the Criminal Records Bureau Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Work is needed to make the home look more attractive and well maintained from outside. However inside service users live in a clean, well maintained environment with rooms personalised to meet their individual needs EVIDENCE: The outside of the home at the main entrance does not do the home justice, with chipped paint, a barely readable sign, and a generally unkempt appearance. A requirement has been made that this area shall be better maintained, cleaned, tidied and made more welcoming. Inside the home is clean and well maintained. There is a shaft lift fitted for access between floors. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 16 A lot of refurbishment has been undertaken since the last inspection including the replacement of the basement windows; fitting of a new door to the kitchen; painting throughout the communal areas and stairwell; repainting of one bedroom; new furniture in another bedroom; and new curtains and nets fitted in the lounge. One area of ceiling has a water stain which has come through the new paintwork and will need to be kept under review other works are planned to be undertaken in the near future. There are two sitting rooms, although both service users normally choose to sit in one of these. Furnishings and lighting in these areas are domestic in character. There is also a dining area in the kitchen. Work has been undertaken on the garden area to provide a new tree shaded area with table and benches, and with ramped access from the basement area on the upper terrace. There are sufficient toilet, washing and bathing facilities to meet the service users needs with hand basins in rooms and toilets provided on both floors. On the lower level there is a wet/shower room and toilet suitable for service users who are wheelchair bound. Service users are accommodated in single bedrooms furnished and personalised to meet their own requirements. There was a recommendation on the last report that the radiator covers needed to be altered so that they have a good and safe finish around the top, edge and corners. Work has been done on these and they are now much less of a hazard. The home was clean, hygienic and free from offensive odours throughout Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A lack of staff files and shortfalls in staff training could put service users at risk. EVIDENCE: The manager currently runs the home with the assistance of her family and friends. Apart from the manager there are three staff employed. 2 staff are on duty throughout the day with a third on call if needed, and 2 sleep in staff are available during the night. When asked if the staffing of the home was adequate to meet their needs service users commented, “pretty good. If I want something they get it for me”, and “The staff are very good. There are enough, no reason for any more”. Currently there is one member of staff with NVQ Level 3, i.e. 33 and although one of them is nearing retirement age a requirement has been linked with other training requirements to include the fact that 50 of the staff should be trained to NVQ level 2 or above. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 18 As previously mentioned all of the staff at the home are all friends or family of the manager. All have had Enhanced Disclosures undertaken by the Criminal Records Bureau. However at present the manager does not hold any files for her staff and a requirement has been made that Staff files shall be provided for all members of staff to comply with Schedule 2 of the Care Standards Act. The home has a system of induction for new staff and this is to be upgraded to comply with the revised Skills for Care Induction package for any new staff employed. A recommendation has been made to support this. Not all staff have undertaken the necessary statutory training and a requirement has been made regarding this. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a friendly, family run home with a manager who treats them as part of the family. Shortfalls in staff training of safe working practices could put service users at risk EVIDENCE: The manager has been running the home for many years, however she has not yet achieved her NVQ 4 in care and management. In view of the fact that she is approaching retirement age, although she has not indicated that she wishes to retire, a recommendation has been made rather than a requirement, that she attain NVQ 4 in care and management. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 20 The ethos in the home is open, friendly, and welcoming and service users are treated as part of the family. Formal quality monitoring strategies are not in place but general discussions are held with service users on a regular basis. There are regular checks on water temperatures, heating and lighting but apart from water temperatures these are not currently recorded. There needs to be evidence that service users are happy and that care managers are satisfied with what is being provided in the home. There also needs to be a way of gathering service users’ views and opinions so that the home can reflect on what has progressed and what is still needed in order to improve and develop. The ongoing home improvements could also be included the development plan. A recommendation was made to design a quality monitoring system and produce a development plan for the home. The home does not deal with the service users finances. Although informal staff supervision is taking place it is not yet formalised or recorded and a recommendation has been made that formal documented supervision of all staff takes place at least 6 times a year. To ensure that safe working practices are in place the home needs to ensure that all staff are up to date with statutory training and a requirement regarding this has been linked to the requirement made under Staffing. All safety certificates viewed were up to date and relevant. Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 17 X 18 3 1 3 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 2 Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 22 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 (2) (b & c) Requirement A daily record must be maintained in the Care Plan and Care Plans must be reviewed with the service user on a monthly basis. The monthly reviews must be documented and the service user should sign to indicate their approval. A copy of the complaints procedure must be prominently displayed in the home The front of the building, outside the main entrance, must be better maintained, cleaned, tidied and made more welcoming and appealing A minimum of 50 of staff should be trained to NVQ level 2 or above. All staff should undertake the necessary statutory training and training in adult protection. All staff administering medication must attend appropriate medication training Staff files, to comply with Schedule 2 of the Care DS0000023200.V301793.R01.S.doc Timescale for action 30/10/06 2 3 OP16 OP19 22 (1) 23 (2) (b) 31/07/06 30/10/06 4. OP28 OP30 OP38 18 (1) (ac) 13 (34) 16 (2) 31/01/07 5. OP29 Schedule 2 30/10/06 Godwyne Hurst Version 5.2 Page 23 6. OP36 18 (2) Standards Act, shall be provided for all members of staff Formal documented supervision of all staff should take place at least 6 times a year 30/10/06 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 Refer to Standard OP30 OP31 OP33 Good Practice Recommendations Induction training should be updated to comply with the revised Skills for Care Induction package The manager should attain NVQ 4 in care and management A formal quality monitoring system should be devised and should include a documented development plan for the home Formal documented supervision of all staff should take place at least 6 times a year 4 OP36 Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Godwyne Hurst DS0000023200.V301793.R01.S.doc Version 5.2 Page 25 - 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!