Inspection on 10/05/05 for Herewards House

This inspection was carried out on 10th May 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

Herewards House 17/04/08

Herewards House 24/04/07

Herewards House 08/06/06

Herewards House 23/01/06

Herewards House 05/10/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE HEREWARDS HOUSE 15 Ray Park Avenue Maidenhead Berkshire SL6 8DP Lead Inspector Sue Burton Unannounced 10 May 2005 09:20 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. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Herewards House Address 15 Ray Park Avenue Maidenhead Berkshire SL6 8DP 01628 29038 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) Mr Bolah Rukunny & Mr Bedanan Guru Seegoolam Mr Bolah Rukunny & Mr Bedanan Guru Seegoolam Care Home 27 Category(ies) of Older Person (OP) registration, with number of places HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 05/10/04 Brief Description of the Service: Herewards House is situated in a quiet residential area of Maidenhead. There is a parade of shops in walking distance with the River Thames close by. The building has been converted and extended to provide residential accommodation for 27 elderly persons. The home has a conservatory with access to the garden, a dining room and separate lounge. Some bedrooms have en-suite facilities. Since July 2004 the home has been under new ownership, and is managed by the proprietors who are jointley registered with CSCI and job share the Registered Managers post. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that commenced at 09.20 on Tuesday 10th May 2005. The previous Deputy Manager had left and the new Deputy Manager Shane Peeroo facilitated this inspection. The Registered Managers who job share the post were not due in to the home until the evening shift and therefore certain records and documents which are kept secure were not available for the inspection. The inspection focused on care plans, resident’s views and the homes environment. What the service does well: What has improved since the last inspection? What they could do better: HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 6 A number of radiators in the home remain uncovered, which was a requirement from the last inspection. Some exterior window frames appear in need of attention and the rear garden needed tidying for residents to use. The home needs to review some areas of the home in regard to health & safety and fire safety. The homes Service User Guide needs further detail added to enable it to fully meet regulation and standard. The home is to improve its provision of infection control resources. 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. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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 HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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) 1,2,3,5 The homes Service User Guide did not contain all the information required by the national Minimum Standards. Residents and their representatives are provided with contracts to sign. The assessment of prospective residents needs is appropriate for the registration of the home. New residents come into the home for trial or respite stays and are able to stay on if long term if wished. EVIDENCE: The homes Statement of Purpose and Service User Guide were pinned on the homes notice board. On examination the Service User Guide did not contain all details as required and did not appear to have been to given out to each resident. Those files examined contained contracts signed by residents or their representatives. The care plans of the most recent admissions to the home were examined and evidenced pre-assessment information gathered from Care Managers and hospitals along with an appropriate assessment from the homes manager. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 9 Files evidenced a number of residents who came to the home for respite care being given and taking up the offer of a long term placement. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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 standard(s) 7,8,10,11 The home now confirms in writing that it can meet resident’s care needs. Care plans provide information for staff to be able to meet resident’s needs and details actions required by staff with appropriate outcomes for the individual. Residents were observed as being treated with care and respect. The home had documented resident’s choices and wishes in the event of their death. EVIDENCE: Four care plans were examined in detail. These evidenced that resident’s needs were fully and appropriately assessed, information included social histories and individuals hobbies prior to entering the home. The new formats used are much clearer and professional and are an improvement from last seen. The new format had a space for residents to sign that they have been consulted in regard to their care at their next review. This area will be followed up at the next inspection. Evidence was seen of nutritional assessment, continence assessments, psychological assessment, and personal safety and risk assessments. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 11 Staff were observed and heard in conversation with residents while giving care and were seen to be considerate and respectful while informal conversation took place. Many of the residents in the home are not able to fully express their thoughts and opinions or communicate effectively but are not isolated from other residents and any activity. There is a quiet lounge for those who prefer not to take part in activities and watch TV. Residents are asked if they wish to have their hair and chiropody done in the privacy of their room or if they wish to stay downstairs in communal areas. Records evidenced that resident’s individual wishes in regard to their funeral arrangements had been recorded. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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 standard(s) 14,15 in part Residents are helped where possible to exercise choice and control. Those residents spoken to thought the food was generally good. EVIDENCE: Files evidenced residents choices being documented in regard to morning routines, choice of newspaper, preferences to where hairdressing and chiropody took place and any likes or dislikes in regard to food. Residents and visitors to the home are not able to identify who is in what role which would be seen as good practice and is recommended. The inspector observed that plastic tumblers are put out at lunchtime, which was not seen to enhance the dining room experience, and discussion took place with the Deputy Manager in regard to changing this. Four residents spoken to gave mostly positive comments about the food, one thought the meat could be stringy. There did not appear to be any consultation process in regard to resident’s choices appearing on the menu. See Std 33. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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 in part A previous requirement that any concerns from residents are recorded had been partly addressed. A previous requirement that the rationale for charging for continence supplies appeared to have been dealt with. EVIDENCE: The Deputy Manager supplied a book, which had been used to record any comments from the residents. One entry was seen with appropriate actions to deal with the issue noted, unfortunately there was no date on the entry, which would have been appropriate. Discussion took place in more detail to the gathering of resident’s comments in Std 33. The home under the previous owners had made a charge for the purchasing of extra continence supplies even though these can be obtained from the NHS where individuals are assessed as needing supplies. Clarification was sought as to whether this practice still existed and if so it should be explained in the homes contract/terms and conditions. The Deputy Manager advised the inspector that charges for supplies if extra were needed are not passed on to the residents. No other aspect of standard 18 was inspected. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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) 19,21,22,25,26 The ground floor interior decor had been improved. The exterior window frames appeared in need of attention, and the garden contained an assortment of old carpets and furniture, which was not conducive to the surroundings. The homes bathrooms & toilets were clean and tidy, the home is recommended to review it health & safety procedures in regard of the use of roller towels. Evidence that a formal assessment of the homes equipment and resources for residents with disability needs was not available. A requirement from the last two inspections that radiators be covered or guarded had not been actioned. An immediate requirement was issued. The home was seen to be clean and pleasant but needed further review of it infection control resources. EVIDENCE: The home has been redecorated and re-carpeted in the hall dining room and conservatory and had a much brighter fresher appearance. The window frames on the front of the house were peeling and in need of repair. The garden, which is for the residents use, had old carpets and furniture at the side and the HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 15 garden generally appeared in need of some time and attention to make it attractive and pleasant to use now that the summer was approaching. A maintenance book is used to record areas checked but did not evidence a programme of planned maintenance for the future. A tour of the home took place with the Deputy Manager; the inspector was advised that the proprietors were currently obtaining quotes to replace on of the homes stair lifts. The decor upstairs in the home is in need of attention. The home has a laundry room on the first floor that contains a large tumble dryer and washing machine, the manager was advised that the door should be consider a “fire door” and closed when unoccupied. The provision of liquid soap and paper towels for staff to use needed to be improved. The arrangements for keeping mops clean and free from contamination was discussed and the home advised to seek and consider what is current good practice guidance. Four of the homes bathrooms/toilets were viewed all found to be clean and tidy. Bottles of shampoo and bubble bath were left out and the Deputy Manager was advised that these should be stored more appropriately. A number of bedrooms were seen and also found to be clean and tidy and very homely with residents own possessions arranged around them. A number of radiators around the house were seen to be no covers or guards on them, which had been a requirement from previous inspections and is considered a risk to resident health & safety. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 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) These standards could not be inspected on this occasion as records were kept secure and the Deputy Manager did not at the time of inspection have access to them. EVIDENCE: HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 17 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) 32,33,35 in part,37,38 Staff in the home are supported and are comfortable with the new management arrangements. The home had a friendly informal atmosphere. The homes quality assurance procedures at the time of inspection had not recorded residents and relative’s views and comments in any depth. Audit trails of the spending of resident’s monies had improved. Confirmation that appropriate Regulation 37 accident reports had been sent in could not be found. EVIDENCE: A number of long standing staff members were spoken to and confirmed that the change in management had been very positive and that they felt comfortable and well supported. They appeared happy with the new Deputy HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 18 Manager and were mutually supportive of each other’s roles. Staff verbally advised that training opportunities had improved. (Documentary records were not available at the time to confirm training undertaken) The staff team do not wear badges and it is not possible to identify them or who is in what role. One staff member was casually dressed like the homes cleaners and it was not clear without asking what her role was see Standard 14. Quality assurance and customer satisfaction surveys were discussed with the new Deputy Manager. The home is recommended to improve its monitoring process as it is recommended that feedback is actively sought from residents, friends family and other interested parties such as GP’s District Nurses etc. Any survey results should be available for prospective residents and CSCI. As records were not available at the time of inspection to monitor that residents finances are handled appropriately a discussion took place with the Deputy Manager and senior carer who advised the inspector that the process had improved and provided a clear audit trail of finances spent on a residents behalf. This will be followed up at further inspections. The home was using the new confidential style accident book as recommended by HSE, unfortunately the tear off reports were kept secure and could be made available during this inspection to check that any serious incidents or accidents had been notified to CSCI and will be followed up at the next inspection. The home should review its fire safety arrangements with the upstairs laundry room. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 19 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 2 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 3 2 x 3 x 2 x HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 20 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 1 Regulation 5 Requirement The service User Guide meets regulation and standard and each resident is proveded with a copy. A copy of the updated guide is to be sent to CSCI This is a repeated requirement. Pipework and radiators are guarded or have guaranteed low temperature surfaces. An action plan is to be sent to CSCI within timescale for addressing the works required to the remaining radiators in the home. This is a further repeated requirement The home is to review its fire safety procedurees in regard to the upstairs laundry room. The home is to actively seek and record feedback from residents and their representatives and this available for inspection and prospective residents. The registered person is to ensure that staff members receive training appropriate to the work they perform. This includes training for all staff in the protection of vulnerable Timescale for action 10/08/05 2. 25 13(4) 10/05/05 3. 4. 19 33 23(4) 24(1) 10/06/05 10/08/05 5. 30 18(1a,c) 10/09/05 HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 21 adults from abuse. All senior staff including night staff are to have manual handling and protection of vulnerable adults training as a priority and confirmation of their attendance is to be sent to CSCI within timescale. This is a repeated requirement 6. 7. 18 19 The Registered Persons ensure that all existing staff members are to have their enhanced CRB checks in place by 31st October 2004.Confirmation that this has been done is to be sent to CSCI within timescale. 10/09/05 8. 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 19 16 19 26 Good Practice Recommendations The home is to review its health & safety procedures in regard of the use of Roller towels in residents bathrooms. The complaints log book is to have all entries dated. Evidence of a planned programme of maintence is to be available for inspection. This is a repeated recommendation Appropriate facilities are to be provided for hand washing. The homes cross infection procedures are to be displayed in all sluices and laundry areas. This is a repeated recommendation The garden is to be tidy, safe and attractive and accessible to residents. An assessment of the home is to be made by a suitably qualified person including a qualified occupational therapist, with specialist knowledge of the client groups catered for. This is a repeated recommendation The home is to consider how staff can be identified by the v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 22 5. 6. 19 22 7. 14 HEREWARDS HOUSE residents and visitors. HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA 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 HEREWARDS HOUSE v217237 h52-h01 60965 herewards v217237 100505 stage 4.doc Version 1.30 Page 24 - 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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