Inspection on 31/01/07 for Goodwins Hall Care Home

This inspection was carried out on 31st January 2007.

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 14/11/05

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 Care Home Goodwins Road Kings Lynn Norfolk PE30 5PD Lead Inspector Mrs Geraldine Allen Unannounced Inspection 31st January 2007 09:10 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 Goodwins Hall Care Home DS0000015639.V329394.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. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goodwins Hall Care Home 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 annette white@hallmarkhealthcare.co.uk Hallmark Healthcare (Kings Lynn) Limited Mrs Annette White Care Home 75 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (65), of places Physical disability (10) Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Sixty five (65) older people may be accommodated, two of whom, who will be named in the Commission`s records, have a diagnosis of dementia. Ten (10) younger adults, who will be named in the Commisson`s records, may be accommodated. 14th November 2005 Date of last inspection Brief Description of the Service: Goodwins Hall is a care home with nursing, providing personal care and accommodation for 65 older people and 10 people with a physical disability. It is owned by Hallmark Healthcare (King’s Lynn) Limited, which is part of the Hallmark Healthcare group. The home is located on the edge of the town of King’s Lynn, close to shops, pubs and other amenities. The home consists of a 2-storey building, with nursing services provided on the first floor. All the bedrooms are en-suite and the majority are used for single occupancy, however there are two double rooms. There are 2 passenger lifts. 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 manager, Mrs White, stated that the current fee range for care and accommodation was between £400 & £500 for residential clients and between £450 & £600 for nursing clients. Prospective residents or their representatives are advised verbally of the applicable fee rate at the time of the pre-admission assessment. The fee rate is also included in the contract of residence and residents or their representatives are given full details of any additional charges that apply. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 31 January 2007. Evidence was obtained from a variety of sources so that judgements could be made about how well the home is performing. Before the inspection, Mrs White provided information about the day-to-day running of the home. Questionnaires sent out by CSCI were received from 10 residents, who answered questions about what it was like to live at Goodwins Hall. Only 1 relative returned a questionnaire. On the day of inspection, a tour of the home was made and all parts were seen. Records were looked at, including the records kept about care given to residents, staff records and records that detail actions taken by the home to protect the health and safety who live, work and visit. Four visitors were spoken to; 2 residents were spoken to at length and another 4 in less depth. Many other residents were seen during the course of the day and spoken to briefly. A meal was eaten with residents in a 1st floor dining room. Overall, the outcome of this inspection shows that care at this home is good. Some elements are judged as excellent. Residents described staff as “wonderful” and provided many examples of their experiences of living at Goodwins Hall. They said they were able to make choices about most things and were confident staff would respect their wishes. Relatives said that the “home is excellent”; that staff were “very approachable”; “nothing is too much trouble” and “everything is very good”. No requirements have been made as a result of this inspection, but 4 recommendations have been made that relate to recognised best practice. What the service does well: The records kept about the care needed for each resident are very good. They provide a great deal of information about each person, what they like and don’t like and how they would like their needs to be met. The home is very well maintained and kept in a good state of decoration. All areas of the home are kept safe. In addition to the training required to be provided by all homes, Goodwins Hall also provides plenty of training to help staff understand the specific needs of each resident. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Goodwins Hall Care Home DS0000015639.V329394.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 Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted to the home only after a thorough assessment of all their needs has been completed. Other agencies and health professionals are involved in the assessment process if necessary. The home provides residents with a contract of residence in most circumstances. This home does not provide intermediate care. EVIDENCE: Three residents files were looked at in detail. These showed that preadmission assessments had taken place. The assessments were thorough and included all aspects of physical, social and emotional needs. There was ample evidence that other agencies were involved in pre-admission assessments as necessary. There was sufficient information obtained to demonstrate that the home could meet all assessed needs. This home does not provide intermediate care. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has their own plan that identifies the care they need and how it is to be delivered. Residents are involved in the planning of their care if they wish. The care plans were well written and regularly reviewed. Evidence was seen that residents receive all healthcare support as and when they need it. The home has robust procedures in place in respect of the control, administration and recording of medicines. Residents said they are treated with respect and in a dignified way. EVIDENCE: Three care plans were looked at in detail. The plans were well presented and the information easy to retrieve. Day and night care plans gave clear and understandable information to staff so that needs were met consistently. Three monthly reviews were recorded and evidenced the involvement of the resident and their relative. Overall, the care plans provided excellent information about each resident’s needs, how they were to be met and by whom, with regular reviews in place. All were up to date, well written and legible. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 10 The care plans provided good evidence that the home works closely with local GP’s and other health professionals. Residents said they were always able to see their GP if needed and the home made all the arrangements for them. The member of staff responsible for the control and dispensing of medicines on 1 floor was spoken to She was very knowledgeable about the residents needs. She also described good, safe practice in the control and administration of medicines. The records were seen and were up to date and legible. Residents spoke freely about their experiences at the home and were complimentary about the care they received and how care staff delivered their care. All felt they were treated with dignity and respect. Residents confirmed that they received care behind a closed door and staff always knocked on their door before entering. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to spend their day where and with whom they please. Visitors are welcomed into the home at any time. Residents make choices about their daily living and are confident staff will respect their choices. Residents are able to choose from a range of options each mealtime and can enjoy their meals in spacious and airy dining rooms or where they prefer. EVIDENCE: Residents said they were able to make many choices about their daily living. They described choices being offered and respected by staff including when they get up and go to bed, food, when they have a bath, attending activities and where they wish to spend the day. Visitors said they felt able to visit the home whenever they wished and were always welcomed by staff and offered refreshment. One visitor said the home was “excellent” and “everything is very good”. She said staff were very approachable and caring. She felt that all staff at the home did what they said they would do and “nothing is too much trouble”. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 12 Residents said that the home had activities every afternoon and the 2 residents at lunch were looking forward to a visiting musician whom they always enjoy Lunch was eaten in one of the 1st floor dining rooms. The room was spacious and allowed easy access for those in wheelchairs. The tables were attractively laid with clothes and flowers. The meal was. The residents spoke specifically about the choices of food available each mealtime. They said they were offered the choices during the morning. Staff were observed assisting residents with their lunch. Most were very discreet and sat in quiet conversation with the resident they were assisting. Communication between the residents and staff during lunch was appropriate. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and visitors to the home know how to complain and feel they will be listened to and their concerns acted upon. Staff have a good understanding of abuse awareness and the home has a commitment to staff training in this area. Residents are protected by good recruitment procedures. EVIDENCE: Residents said they knew about the complaints procedure and would speak with Mrs White or another member of staff if they had any concerns. Visitors were also aware of the complaints procedure and felt if they had any concerns that they would be listened to and acted upon. The home’s complaints records were seen. There was evidence of good practice and all expressions of concern or complaint were fully recorded and appropriate actions taken in accordance with the procedure. Those staff spoken to had a good understanding of abuse awareness. Practice seen throughout the day was appropriate and non abusive. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well maintained and in an excellent state of décor. All areas were free of hazard. The home was clean, tidy and free of unpleasant odours. EVIDENCE: A tour of the premises was conducted with Mrs White. All areas of the home were clean and the décor in a very good state. All corridor carpets have been replaced and the corridors redecorated. Bathrooms are assisted and have items to make them appear more domesticated. All have window coverings, decals on the walls and plants. The dining rooms were spacious and light. There was ample space between tables to allow the easy passage of wheelchairs. Each dining room had a kitchenette attached for residents and their visitors to use. The dining room tables were attractively laid for lunch, with cloths, cloth napkins and flowers. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 15 Lounges were located in each wing on each floor. These were very comfortable and well furnished, with various seating available. The lounges were furnished to make them feel and appear domestic. There were plenty of communal spaces offering residents choices as to where they spent the day. The laundry was equipped with industrial washers and dryers, enabling soiled laundry to be disinfected at high temperatures. The laundry was well organised and staff described good practice regarding infection control. All areas of the home were clean and tidy and there were no unpleasant odours. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates good staff recruitment practices that help protect residents. Staff are employed in sufficient numbers to meet the needs of residents. Ancillary staff are employed to ensure care staff are not required to undertake any domestic or laundry tasks. Staff receive training that is relevant to the residents at the home. EVIDENCE: The staff files for 3 members of staff were looked at in detail. The files were comprehensive and kept in good order with all information easily retrievable. The signing in sheet for the day of inspection was provided. This showed that 2 nurses and 11 care staff were present to provide care during the morning. Also, in addition to the manager, there were 3 domestic staff, 2 laundry staff, 1 ward orderly, 1 cook & 1 kitchen assistant, 1 gardener, 1 maintenance person and 1 administrator. These levels were in accordance with staff rotas previously provided and demonstrated good staffing levels at the home. Residents and visitors said that they felt there were enough staff on duty and residents said that staff were usually able to come to them when they needed them. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 17 In addition to statutory training requirements, staff files also evidenced significant additional training that was relevant to the needs of the residents. The home currently has 5 staff who are qualified manual handling trainers and 8 staff who are NVQ assessors. One assessor is the cook, who undertakes NVQ assessments for catering staff. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is well qualified, experienced and competent to fulfil her role. Good processes are in place to ensure regular review of quality issues. The home has good practices in place when handling personal allowances on behalf of residents. Staff receive formal supervision every 2 months and this is recorded. The home monitors accidents and takes steps to reduce risk where possible. EVIDENCE: Mrs White is an experienced manager who is well qualified and competent. As part of the home’s quality assurance process, Mrs White undertakes monthly audits of the home and its operations. The arrangements for looking after money on behalf of residents were discussed with the administrator. All actions are counter-signed with initials Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 19 rather that signatures. There was evidence of regular auditing of the monies held taking place. Each person’s money is kept in a separate zip up wallet and stored in a looked safe. The money held for 1 resident was checked against records. All receipts were in place and the amount was correct. The arrangements for staff supervision were discussed with Mrs White. She confirmed that all staff sign the supervision contract and the process is cascaded through to senior staff. All supervision is recorded using the company documentation and each member of staff was receiving supervision every 2 months. A record of these events was seen but individual supervision records were not seen. Accident records were looked at. These are kept on each resident folder once completed. Mrs White undertakes a monthly audit of all accidents and confirmed she looked for patterns of occurrence and was to reduce the level of incidents. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP3 OP7 OP29 OP35 Good Practice Recommendations It is recommended that pre-admission assessments are signed and dated on all occasions. It is recommended that the new “lifestyle” care plan is implemented as soon as possible so that staff are aware of the social activities of interest to each resident. It is recommended that interview notes are fully completed for all staff interviews. It is recommended that two signatures, and not initials, are obtained for all financial transactions carried out on behalf of residents. Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Goodwins Hall Care Home DS0000015639.V329394.R01.S.doc Version 5.2 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. 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