Inspection on 29/07/05 for Goodwins Hall Care Home

This inspection was carried out on 29th July 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 14/11/05

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 Jenny Rose Unannounced 29th July 2005 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 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 I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Goodwins Hall Address Goodwins Road, Kings Lynn, Norfolk, PE30 5PD 01553 777994 01553 777996 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 (47), of places Physical disability (9) Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered to provide nursing care for up to 75 service users. 47 can be older people, 19 older people with dementia and 9 younger people with a physical handicap. Date of last inspection 6th December 2005 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 I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 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. The Manager, Mrs Victoria Hurlock, was in attendance during the inspection. There were 71 service users in residence. Preparation took place in the CSCI office, there was a tour of the building and many records seen. Four members of staff were spoken to privately, as well as one visitor and six service users. What the service does well: What has improved since the last inspection? What they could do better: * There should be continuing efforts in one Unit to keep it free from odours. * There should be risk assessments for service users observed asking for their medication to be left until they had finished eating, or a change in the timing of the administration of the medication. Please contact the provider for advice of actions taken in response to this Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 6 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 I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 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 standard(s) 3 There is a pre-assessment procedure to ensure that the service user’s needs can be met by the home. EVIDENCE: A pre-assessment for a new service user was seen and this was undertaken prior to admission by the Manager, or it could be by one of the senior staff on other occasions. The Manager explained visits are made to the prospective service user’s home or in hospital to carry out an assessment to ensure that the home can meet their needs. The service user can, if possible, visit the home prior to admission, as well as relatives and/or their representatives to be assured that needs will be met. Other healthcare professionals are involved, if appropriate. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 There are comprehensive care plans and policies and procedures for administering medication, which ensure that the changing needs of service users are met and they are protected. EVIDENCE: The pre-admission assessment forms the basis of the care plan. The care plans seen were comprehensive and contained appropriate risk assessments. There were photographs of service users and the plan was signed either by the service user and/or their representative. Advice was also sought from other healthcare professionals, such as the Continence Adviser, the Community Nurse, optical reports and a separate section for GP visits and reviews of medication. There were also regular monthly reviews with service users and/or their representatives if necessary. There were life histories and preferences in all the care plans seen, including funeral arrangements. There was also a separate book of service users’ life histories in more detail, if service users wished, some containing photographs of service users’ youth. The section for Daily Living Activities contained much detail divided into physical, psychological, social care and a night care plan. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 10 A risk assessment was seen for a service user who wished to smoke and this was seen to be reviewed regularly. One service user, who is hoist dependent, commented that she felt there was sometimes a delay in staff answering her call bell. The Manager explained that there was a computerised monitor of call bells and that any delay over 5 minutes was deemed unacceptable and investigated. The Medication round was observed in the Nursing Unit. An MDS was administered from a locked trolley. The MAR sheets were seen to be in order and had photographs of service users. There were no service users who were administering their own medication, but there were policies for this. However, there is a recommendation that there should be risk assessments for service users who were observed asking for their medication to be left on the table at mealtimes until they had finished eating. Medication was stored in a locked medication room with Controlled Drugs Cabinets for the separate units. Medication in the Nursing Unit cabinet was checked randomly and was correct. The recommendation from the last inspection that the medication room door should be painted is repeated as this work has not been carried out. It was observed and confirmed by service users spoken to that service users felt staff treated them with respect and dignity. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 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 standard(s) 12, 13, 15 The activities organised by the home, an open door policy on visiting and a varied menu provide variety and interest in service users’ daily lives. EVIDENCE: The home employs two activities organisers, who keep weekly records of activities, which are in turn recorded in service users’ care plans, which is good practice. There is Music and Movement, Reminiscence, Crafts, Cooking, a fete, raffles and a quiz with service users, relatives and staff. There is a bi-monthly newsletter, and the WEA have run courses on pottery, card making and salt dough. There is a computer course planned and some service users have taken part in embroidery. There have been outings, which service users confirmed they enjoyed and photographs are planned to be published in the news letter. There is a visitor who provides a ‘Pat Dog’ service with her huskies. Students from the College of West Anglia had been involved in creating a garden and they visit to serve teas and coffees to the service users. There is a non-denominational service held in the home once a month and representatives from service users’ own churches visit on request. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 12 There were several visitors to the home during the day and service users confirmed that they are able to receive them when they wish and also to go out with staff if they wish. One visitor spoken to visits frequently during the week and joins in the activities with her relative if appropriate. There are three dining areas and service users can choose to have their meals where and with whom they wish. The visitor and the service users spoken to expressed positive opinions about the food and the choices given. Service users made their choices from the menu the previous day, but it was observed that they could alter this at the actual meal time. The lunch was seen to be nutritious and appetising and attractively presented from a hot trolley. One service user commented: “The food is very good and I choose to go downstairs to eat it”. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 13 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 standard(s) 16, 18 There is a complaints procedure and service users, relatives and representatives assured that their complaints are taken seriously and acted upon. The whistle blowing policy and procedure for the protection of vulnerable adults as well as the staff training in these issues ensure that service users are protected as far as possible from abuse. EVIDENCE: The home had a complaints procedure in place and service users and staff spoken to were aware of this and felt able to put it into practice if necessary. Complaints are kept on file, the last being on 7 June, which was in the process of being dealt with. There was a compliments book and events book on display in the hall. The visitor spoken to confirmed that she had had occasion to make a minor complaint, but she was satisfied that this received prompt attention and was satisfactorily resolved. The home also has a whistle blowing procedure and a policy for the protection of vulnerable adults. All staff receive training in the protection of vulnerable adults together with other mandatory training. The staff spoken to were aware of the issues surrounding adult protection. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 23, 25,26 This is a safe, well- maintained comfortable environment, inside and out, for service users. Continuing to address the problems of carpet odours in the EMI Unit would make for a more pleasant environment for service users and their visitors. EVIDENCE: This is a purpose-built home, in which seventy one of the seventy five bedrooms are single, all with an en-suite facility. There are a number of communal areas where service users can choose to sit and see visitors, as well as their rooms. There are three dining rooms and service users can choose which to use. There is a high standard of maintenance and decoration. Outside there is a secure garden, where on the day there was a gazebo and garden furniture to afford service users some shade and where there was some ‘sensory’ planting. There is also a small vegetable garden with a greenhouse, should service users wish to use this. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 15 There is another area of garden , in which service users were sitting, with an arched walkway, a statue, bird nesting boxes, a fish pond and a statue. and this garden has been entered for the second time into the Hallmark ‘Garden in Bloom’ award. There is also a Garden of Tranquility, where service users’ families can choose to put memorials. The gardens provide an attractive area for service users and this is to be commended. On the nursing home floor there is a ‘shop’ for sweets, and toiletries, etc,which is run by the service users and there has been an addition of some new pictures. On this floor there is a sitting area which has been made more domestic in appearance by the addition of a decorative fireplace with horse brasses. Service users’ rooms were seen to be personalised and furnished, if not with their own furniture, with furniture of a high standard. Service users can bring their own beds if they wish, providing they are of the appropriate standard. There is a relatives’ utility room where drinks can be made and a trolley in the reception area with many information leaflets, including an advocacy service. Bathrooms had been decorated with themes by members of the staff; service users could choose in which room to bath, including one bathroom with a Jacuzzi. However, there is a shower room, which is no longer used and where hoists are stored. The medication room door on the ground floor is scuffed and there is a repeat recommendation that this should be repainted. There were some areas in the Dementia Unit where there were odours from carpets. The home has a system for dealing with these by placing yellow stickers on the doors of the rooms where carpets need cleaning and chalk marks on the areas which need immediate attention; also the Manager was trialling an ‘ioniser’ in one area. However, there is a requirement that measures should continue to be taken to counteract this problem, or the carpets replaced. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 There appears to be good communication between the staff in separate units and the home’s emphasis on training provides a high standard of care for service users. EVIDENCE: All the staff spoken to were enthusiastic about their work. They expressed appreciation of the training opportunities and of the staff team in the home as a whole. There were regular staff meetings, as well as emergency staff meetings, for both day and night staff, if necessary. They also said that the Manager was approachable and that they felt able to discuss any problems with her. Training has a high priority in the home. All staff, domestic, as well as care staff undergo TOPSS training and NVQll and beyond. Also Adaptation Training is provided for staff where appropriate. All staff on the Dementia Unit have received training in dementia and there are notes in care plans regarding inhouse training on aggressive behaviour and de-escalating techniques. Several members of staff have undergone Fire Warden training. The home promotes cluster training involving other homes and it is planned for UEA to hold a Diploma Course under this scheme, using the home’s training room. There are many in-house incentives for staff and one member had recently been awarded ‘Carer of the Year’ within Hallmark and would be entered for the national competition later this year. This same member of staff has also been appointed as a ‘Care Ambassador’ locally, to visit local schools and other Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 17 educational establishments in order to promote caring as a career. This is to be commended. The staff files are comprehensive, containing all the relevant documents with details of regular supervision and annual appraisals. One service user commented: “The staff are all very kind” and there were positive remarks from other service users. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36, 38 The management is open and inclusive and by service users’ meetings and surveys endeavours to ensure that the home is run in the best interests of service users. EVIDENCE: There is a clear management structure, which is displayed in the staff rest room areas which are equipped with chairs, tables and vending machines. There is a Manager, her Deputy and two other Unit Managers. The Manager is awaiting her NVQ 4 verification. There appears to be good communication between the units, who each hold their own staff meetings, there is also a ‘Hotel’ Manager who supervises the domestic staff, all of whom do TOPPS and NVQ training. This Manager also deals with recycling issues within the home. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 19 From discussion with staff and service users it is clear that the management in the home is open and inclusive. There are meetings for service users once a month and it will be noted from another section of this report that there is a service users’ committee. The home conducts regular service user satisfaction surveys, as well as staff surveys. The local GP practices had been sent a questionnaire, but there had been none completed. The next survey for service users planned was one on food. The home is renewing its Investors in People Award, and considering participating in the ISO9002 award this year. The record of incident/accidents was seen and the Manager said that an audit of falls was being monitored to provide data for a Falls Prevention survey. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 x 2 2 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x 3 x 3 Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 21 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 25 Regulation 16 (2k) Requirement The Registered Person shall make continuous efforts to keep the home free from offensive odours Timescale for action Immediate and ongoing 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. Refer to Standard 19 9 Good Practice Recommendations It is recommended that the medical room door be repainted. It is recommended that risk assessments are carried out on those service users wishing to delay their medication until they have finished eating, or change the timing of the administration of the medication. Goodwins Hall Nursing & Residential I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 I55 s15639 goodwinshall v233770 290705 stage 4.doc Version 1.40 Page 23 - 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. 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