Inspection on 23/01/06 for Herewards House

This inspection was carried out on 23rd January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Herewards House 17/04/08

Herewards House 24/04/07

Herewards House 08/06/06

Herewards House 10/05/05

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 Susan Burton Unannounced Inspection 23rd January 2006 09:50 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 DS0000060965.V279571.R01.S.doc Version 5.1 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. DS0000060965.V279571.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Herewards House Address 15 Ray Park Avenue Maidenhead Berkshire SL6 8DP 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) 01628 29038 Mr Bedanan Guru Seegoolam Mrs Dhanwantee Seegoolam, Mrs Sangeeta Rukunny, Mr Bolah Rukunny Mr Bolah Rukunny Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places DS0000060965.V279571.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 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. DS0000060965.V279571.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Monday the 22nd of January 2006, which commenced at 09.50 hrs. Neither of the Registered Managers/Proprietors were present during this inspection and the process was enabled by the homes administrator and senior care assistant. The absence of the managers resulted in limited access to staff records and therefore certain areas of the inspection will be followed up either by direct communication with the proprietors or at the next inspection. The inspection followed up the requirements and the recommendations from the previous inspection and also focused on activities, medication, nutrition and feedback from the residents in the home. What the service does well: What has improved since the last inspection? The home has been redecorated externally and the grounds tidied up, the driveway has also been re-tarmac to provide a safer walking surface. The ongoing programme of redecorating and recarpeting the interior continues. The home has completed its Statement of Purpose and Service User Guide and has also now completed the programme of covering the radiators in the home. Care plan documentation has improved in the detail recorded, residents likes and dislikes and personal choices are recorded. DS0000060965.V279571.R01.S.doc Version 5.1 Page 6 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. DS0000060965.V279571.R01.S.doc Version 5.1 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 DS0000060965.V279571.R01.S.doc Version 5.1 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): 2,3 Contracts/Terms and conditions are in place but the content needs to be reviewed. Pre-assessment information is recorded and collated from other health professionals. EVIDENCE: The inspector examined the contract/terms of conditions of three new admissions. The contract was seen to include out of date legislation, which is no longer relevant. The home is recommended to review these documents to ensure they are up-to-date and appropriate. Pre-assessment information from the last three admissions to the home evidenced that the home collates information about an individuals health and well-being from other health related professionals. A full assessment is undertaken by the manager to ensure that the home is suitable for the individual. DS0000060965.V279571.R01.S.doc Version 5.1 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): 7,8,9 Residents personal and social care needs are set out in an individual plan of care. Residents health care needs are recorded and staff ensure that referrals to other health services are facilitated. Medication Administration charts are to be accurately completed. EVIDENCE: The inspector examined care plans of the three most recent admissions to the home and found that the degree of detailed information had improved since the last inspection. Care plan detail included food preferences, social history, and residents individual preferences at the time they wish to rise in the morning and when they wish go to bed. The home confirms in writing that it is able to meet the needs of prospective residents. Risk assessments and reviews were seen. DS0000060965.V279571.R01.S.doc Version 5.1 Page 10 Residents individual health-care needs are detailed within the care plan. Any referrals to outside clinics or hospital appointments are arranged. Residents weights were seen recorded and individual continence requirement assessed. There were some blank spaces in the medication administration records where it is not clear if medication has been given as prescribed by the doctor. For all regular medication there should be a signature of the member of staff administering the dose, or a clear reason for omission recorded. It is a requirement to keep an accurate record of all medicines administered. DS0000060965.V279571.R01.S.doc Version 5.1 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): 12, 13, 14, 15 Recreational activities need to meet the needs and expectations of the residents. Residents are enabled where possible to maintain contact with the local community, friends and relatives. Residents individual choice and preferences are recorded and acknowledged. A previous recommendation that the home consider how staff could be identified had not been acted on. Residents and relatives spoken to responded that the food was good. The home is to review the provision of the evening meals to ensure they are appropriate for winter temperatures. EVIDENCE: The inspector found a small notice detailing activity provision, this appeared somewhat limited. There was no activity/recreational event taking place during the time of the inspection. A relative who visits on a regular basis also commented on what a long day it could be for the residents. The home should review its activity provision to ensure it meets residents expectations, abilities DS0000060965.V279571.R01.S.doc Version 5.1 Page 12 and needs and is competently provided. Staff advised the inspector that they read to the residents and play ball games but this was not seen and did not appear to be enough activity for the number of residents and their differing abilities. The inspector on arrival at the home could not identify which staff were working and in what capacity as not everyone wore a uniform and no name badges seen on any staff members. This was a recommendation from a previous inspection that had not been acted on. Care plans had documented individual residents likes and dislikes in regard to food and had also acknowledged the individuals routines in regard to when the resident wished to get up in the morning and at what time they preferred to retire in the evening, which is good practice. One gentleman is taken out shopping on a regular basis after lunch by the staff to enable him to purchase his cigarettes. Staff are currently pursuing contact with the local church for one new residents spiritual needs. The inspector examined the homes menus and spoke to the chef in charge at the time of the inspection. The main meal of the day is served at lunchtime; on the day the inspection this was chicken casserole or fish fingers. Relatives and residents spoken to during inspection confirmed that they were satisfied with the quality and quantity of the food provided in the home. The supper/evening meal was recorded as sandwiches and ice cream; the inspector was of the opinion that this was not an appropriate provision for the residents when the weather outside was below freezing. The home is required to review its menu selection to ensure that hot food is provided in the evening during cold weather. DS0000060965.V279571.R01.S.doc Version 5.1 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 the following standard(s): 16,18 The homes complaints log contained a written complaint from a relative, which made serious allegations about medication administration. The inspector was not able to see if any investigation had taken place or what the outcome was of the allegation. A requirement made at the last inspection that all staff receive training in the protection of vulnerable adults had been partly acted on. The staff member in charge of the home on the day of inspection had not had any recent adult protection training and was not aware of the local interagency guidelines for the protection of vulnerable adults EVIDENCE: The inspector found a letter from a relative making an allegation in regard to medication practices in the home. The inspector could not see/access any records, which detailed what action or investigation had been undertaken by the home following receipt of this letter. Contact was made with the proprietor by telephone to discuss the serious nature of the complaint and the lack of evidence for a satisfactory outcome as required in the regulations. A full explanation was given in an open and constructive dialogue from the proprietor. The inspector was assured that residents were not at harm from any serious malpractice. The proprietor was asked to send full details of their investigations separately to CSCI. Only five members of staff had attended Adult Protection training (this number included the chef) DS0000060965.V279571.R01.S.doc Version 5.1 Page 14 The staff member in charge of the home could not find/access the homes policy and procedures on the protection of vulnerable adults and did not seem to be aware of the correct procedures to follow should an allegation of abuse be reported to her. The home is required to appropriately train those members of staff left in charge in the protection of vulnerable adults. Staff should be able to access relevant policies and procedures to ensure they follow recommended guidelines. DS0000060965.V279571.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 The proprietors have continued to decorate the home both externally and internally to ensure that a comfortable and homely environment is provided. The inspector visited a number of bathrooms in the home, the majority of which are not used. The main bathroom on the first floor is in need of redecoration to ensure that a fresh and pleasant environment is provided for those residents who need assistance with bathing. A previous recommendation that appropriate facilities are provided for hand washing in the laundry room had been partly acted on. EVIDENCE: The external frontage of the home has been decorated and the driveway resurfaced to provide a safe and level pathway. The garden of the home has been tidied and cleared and is programmed to have further development to provide pleasant surroundings for the residents. The proprietors have replaced the old ground floor stairlift with a newer modern version, which looks more DS0000060965.V279571.R01.S.doc Version 5.1 Page 16 comfortable and appears safer. The program of redecoration has continued with more new carpets being laid. The main bathroom is a large room but is dimly lit and is in some need of redecoration. The bathroom looked dated with peeling wallpaper and ceiling cracks and did not feel conducive to a pleasant and comfortable bathing experience. A recommendation had been made at the last inspection that appropriate facilities be provided for hand washing within sluices and laundry areas. The inspector visited the laundry and found that there were no facilities for the drying of hands, which is necessary to prevent the spread of infection. The recommendation has been repeated. DS0000060965.V279571.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The numbers of staff on duty met residents care needs on the day of inspection. From examination of the training records it appeared that the home has not achieved 50 of its care staff with NVQ 2 or above. Recruitment records are kept securely in the Registered Managers absence but could not be accessed during this inspection. Training records evidence some progress has been made in meeting the training needs of the staff team, the training needs of those staff left in charge of the home are to be reviewed. EVIDENCE: Examination of the homes shift rotas evidenced 6 members of staff on the morning shift, this number was seen to be appropriate to meet the physical care needs of the 21 residents in the home at the time of this inspection. The rota evidenced that the one of the Registered Managers was present in the home for 3 shifts the previous week and for this week was written down to attend for one shift, the senior member of staff on duty advised that the manager was often there at times other than what appeared on the shift rota with the other registered manager attending evenings and weekends. This was not made clear on the existing shift rotas. It is a requirement that the homes shift rotas accurately reflect management shifts worked to evidence their attendance in the home. DS0000060965.V279571.R01.S.doc Version 5.1 Page 18 From examination of the homes training records provided to the inspector, only 4 members of staff appeared to have achieved NVQ level 2 or above at the time of inspection. The inspector was advised that there were a further 4 members of staff in progress with their NVQs. It is recommended that the home achieved 50 of its care staff with NVQ 2 or above. Neither of the Registered Managers were present during the inspection although telephone contact was made later. The recruitment records are kept secure in a locked filing cabinet and the homes administrator and senior carer who was in charge of the home did not have access to these records, therefore the standard could not be effectively inspected. Discussion took place with the managers by phone on how they can facilitate access to records when requested by the commission. The home is required to review its access arrangements. The home is also required to confirm in writing to CSCI that all existing staff have had their POVA and CRB checks completed, this was a requirement at the last two inspections. The senior carer in charge of the home provided the inspector with the homes training file. This evidenced that training had taken place for a limited number of staff in adult protection, food hygienie, first aid, fire training, medication and health and safety. The staff member in charge of the home at the time of inspection was very experienced but had not had recent up-to-date adult protection training, up-to-date medication training or first aid training which would ensure her competency to be left in charge of the home. Discussion took place with the managers by telephone after the inspection in regard to the competancy of those staff members managing the home in their absence and a review of the arrangements was agreed. The homes Registered Managers are considering the current management arrangements in the home and changes may take place in the future. DS0000060965.V279571.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 38 Access to the management and administration records of this home were limited by the Registered Managers absence, a requirement has been made for this to be reviewed. A requirement had been made of the last inspection at the home was to actively seek in record feedback from the residents and their representatives, no evidence of this was found or was available at this inspection. The homes bathrooms are to be provided with appropriate storage facilities for the protection and safety of the residents. EVIDENCE: The staff in charge of the home could not find or make available any evidence to confirm that a requirement made at a previous inspection that the home actively seek and record feedback from residents had been done. Therefore this requirement is repeated. DS0000060965.V279571.R01.S.doc Version 5.1 Page 20 The inspector visited all of the homes bathrooms; it appears that the large bathroom on the first floor is the one that is used by the majority of residents. Advice had been given at the last inspection that bottles of shampoo, bubble bath and other liquids and ointments be stored out of sight in an appropriate facility to prevent any residents ingesting the contents. It is required that appropriate storage facilities are provided to prevent any potential for harm to residents. DS0000060965.V279571.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X X X 2 DS0000060965.V279571.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP30 Regulation 18 (1) a, c Requirement The registered person is to ensure that staff members left in charge of the home receive training appropriate to the work they to perform. This includes training in the protection of vulnerable adults, health & safety and first aid. The registered person/s actively seek and record feedback from residents and their representatives, this information is to be available for inspection. Repeated requirement. That accurate records are kept of all regular medication administered, or a reason for omission recorded if a dose is not given. Any complaint made under the homes complaints procedure is to be fully investigated and full documentary evidence of outcomes are to be available for inspection. The homes activity programme is to have regard to the needs and abilities of the residents and be provided on a regular basis. DS0000060965.V279571.R01.S.doc Timescale for action 23/03/06 2 OP33 24 (1) 23/03/06 3 OP9 13(2) 23/02/06 4 OP16 22 (3,4) 23/03/06 5 OP12 16 (2) n 23/03/06 Version 5.1 Page 23 5 OP18 13 (6) 6 OP19 23 (4) 7 OP15 16 (2) i 8 9 OP38 OP29 13 (4) c 17 (3) b sch 3,4 10 OP29 17 (2) 11 OP27 17(2) Schedule 4 Copies of the local inter-agency guidelines for the protection of vulnerable adults along with the homes policies and procedures are to be available to staff. The registered persons are to confirm in writing to CSCI that the home has complied with the Berkshire Fire and Rescue Services Fire Deficiency notice The home is to review its menu provision of evening meals to ensure hot food is always available during cold weather. Appropriate storage facilities are to be provided in bathrooms. The registered persons are to review how records referred to in regulation 17 (2), schedules 3 and 4 are made available for inspection by CSCI. The registered persons confirm in writing to CSCI that all existing staff working in the home have POVA and CRB checks completed and that new employees checks are completed prior to employment. Repeated requirement. The homes duty rosters accurately reflect the Registered Managers/Proprietors shifts worked. 23/02/06 23/03/06 23/02/06 23/02/06 23/03/06 23/02/06 23/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations Appropriate facilities are to be provided for hand washing. The homes cross infection procedures are to be displayed in all sluices and laundry areas. DS0000060965.V279571.R01.S.doc Version 5.1 Page 24 2 3 4 OP14 OP2 OP21 5 OP28 This is a repeated recommendation. The home is to consider how staff can be identified by the residents and visitors. This is a repeated recommendation. Contracts/terms and conditions supplied to residents and their representatives are reviewed to ensure that out of date legislation is not included. The main bathroom is to be refurbished/redecorated to ensure that a pleasant and comfortable bathing experience is provided with facilities appropriate to the needs of the residents. A minimum ratio of 50 of members of the care staff achieve NVQ level 2. DS0000060965.V279571.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks 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 DS0000060965.V279571.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!