Inspection on 14/11/05 for Goodwins Hall Care Home

This inspection was carried out on 14th November 2005.

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

The inspector 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

Goodwins Hall Care Home 26/11/07

Goodwins Hall Care Home 31/01/07

Goodwins Hall Care Home 29/07/05

Goodwins Hall Care Home 06/12/04

Goodwins Hall Care Home 15/07/04

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

CARE HOMES FOR OLDER PEOPLE Goodwins Hall Nursing & Residential Goodwins Road Kings Lynn Norfolk PE30 5PD Lead Inspector Mrs Jacky Vugler Unannounced Inspection 14th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 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. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Goodwins Hall Nursing & Residential Address Goodwins Road Kings Lynn Norfolk PE30 5PD 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) 01553 777994 01553 777996 carole.smith@hallmarkhealthcare.co.uk/vi Hallmark Healthcare (Kings Lynn) Limited Mrs Victoria Hurlock Care Home 75 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (46), of places Physical disability (10) Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten (10) Younger adults, who will be named in the NCSC records, may be accommodated. 29th July 2005 Date of last inspection Brief Description of the Service: Goodwins Hall is a purpose built home on the edge of the town of King’s Lynn. There is accommodation for seventy-five service users and the home is registered for residential and nursing clients including provision for nineteen people who have dementia in a separate wing. The accommodation is on two floors and there are two passenger lifts serving the first floor. All the bedrooms are en-suite and are mostly single, however there are two double rooms. All the rooms are a good size. In addition there are: Five assisted bathrooms, one with a Jacuzzi. Five independent showers. Assisted separate toilets on each floor. There is a large reception sitting area. The home comprises six lounges and five dining rooms situated on both floors with the provision of a quiet room, a small library room, a craft room and a small smoking room. In addition there are offices, treatment room, sluice facilities, storage rooms, laundry and kitchen, training and staff facilities. There is a visitors’ toilet in reception, and tea and coffee making facilities are also available for visitors’ use. There is a large car park to the front of the building and extensive grounds around the building, which are accessible to service users. The home is set in two acres of landscaped gardens with walkways and seating areas among the rose beds. The home has been awarded the Hallmark ‘Gardens in Bloom’ award. There is also a Garden of Remembrance and seating is provided at intervals throughout the gardens. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on a weekday over 7 hours. Mrs Vicki Hurlock (Manager) and Mrs Annette White (new Manager) were in attendance during the inspection. This inspection occurred on the first day of the induction for Mrs White. Preparation for this inspection took place in the CSCI office. There were seventy-three residents accommodated at this time. A tour of the building was undertaken and many records were viewed. Six residents were spoken to privately and six together in the lounge. Two visitors were spoken to and six members of staff. Seven comment cards were received from residents and another was completed on behalf of the resident. Two comment cards from relatives were received. One resident was not happy with the standard of food provided, and this resident seemed generally dissatisfied with the home. One commented on the loss of personal items in the dementia unit and one card commented that there were not sufficient staff on duty. All other comment cards received were positive about the standards of care offered by the home, the staffing levels and the food provided. What the service does well: During discussions with residents and visitors, many favourable comments were made regarding the staff including, “I’m ever so happy with the staff, we have a joke”, “the carers are fantastic”, “the night staff are excellent”, “the staff are fun, they are really nice”. A friendly, relaxed atmosphere between the residents and staff was observed and many of the staff spoke highly of working in the home. There are comprehensive care plans to enable staff to meet residents’ changing needs and very good training opportunities for staff. The majority of the residents and visitors commented positively on the food served saying, “the food is excellent”, “the food is very good and we have a choice”. However, there were two adverse comments received. There are a variety of communal areas where residents and their visitors can choose to sit. There is an informative bi-monthly newsletter and a variety of activities with two dedicated organisers and a residents committee. The gardens are of a high standard and accessible to residents. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 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 Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 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): 6 This standard is not applicable. EVIDENCE: These standards were not assessed on this occasion. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 9 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): 9 & 10 Personal support is offered in such a way as to promote and protect the residents’ privacy and dignity. The overall practices regarding medications were satisfactory, although a requirement and some recommendations have been made to further improve the safety of medication practice. EVIDENCE: It was observed and confirmed by residents and their relatives spoken to that the residents felt the staff respected their privacy and dignity. The inspection of the medication standard was conducted simultaneously by pharmacist inspector Mr M Andrews. Overall, he found the home’s medication practice to be satisfactory, however, he made several recommendations in order to enhance the safety of medication administration practice. The inspector identified some inadequacies in the record keeping for the administration of medicines in particular those prescribed for external application. He also found that for service users self-administering medicines Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 10 there were inadequacies in storage and risk assessments. Finally in relation to controlled drugs a quantity of morphine sulphate tablets were identified as unaccounted for. An enquiry into the fate or location of these medicines is therefore required. A full pharmacy inspection report has been sent to the provider alongside this report and is available subject to request. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 11 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): 14 The residents are helped to exercise choice and control over their lives. EVIDENCE: A number of people living in the home were spoken to and everyone commented on the choices available, one comment was “there’s lots of choice, it’s easy living here”. One resident spoke of the activities provided and said that he likes to take part in some activities, for example a sing-song and quiz, but he doesn’t have to take part in the other activities. Another resident spoke of her choice of where to take her lunch. One resident spoken to said, “sometimes the food is good and sometimes it is almost poor”. All other comments from the residents about the food were favourable. Because of the few adverse comments regarding the food, four weeks menus were viewed and these were nutritious and varied. They showed a choice at lunchtime and teatime and residents confirmed this. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed on this occasion. EVIDENCE: Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 13 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 & 26 This is a safe, comfortable and well-maintained environment. EVIDENCE: As recommended at the last inspection, the door to the medical room has now been repainted. The home is making continuous efforts to address the problem of carpet odours in the dementia unit. The carpet-cleaning schedule continues and there is now an ioniser in place, which is reported to be effective. During the inspection malodours from the carpets in this area were less noticable. Mrs Hurlock advised that the carpets throughout this area are due to be replaced early 2006. Until these carpets are replaced, continuous efforts should be made to keep this unit free from odours. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 14 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): 29 The procedures for recruitment are robust and provide a safeguard to offer protection to residents living in the home. EVIDENCE: The staff files of seven staff members were viewed and these showed all the relevant recruitment checks including Criminal Records Bureau disclosures. Three additional work permits were seen on files and the qualified nurses registration numbers were also viewed and in date. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 15 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): 35 Good record keeping safeguards the residents’ financial interests. EVIDENCE: The financial records are well kept and regularly audited by two members of staff. Receipts are kept as well as a record of income and expenditure. Twelve residents monies were randomly checked and these were all correct. Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 16 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 x x x Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP26 Regulation 16 (2k) Requirement The registered person must make continuous efforts to keep the home free from offensive odours. Timescale for action 30/11/05 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 Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Goodwins Hall Nursing & Residential DS0000015639.V255466.R01.S.doc Version 5.0 Page 19 - 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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