Inspection on 01/11/06 for Rayleigh House

This inspection was carried out on 1st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Rayleigh House 16/02/09

Rayleigh House 18/11/05

Rayleigh House 23/05/05

Rayleigh House 10/02/05

Rayleigh House 21/10/04

Rayleigh House 26/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Rayleigh House 17 Derby Avenue Skegness Lincs PE25 3DH Lead Inspector Mr Ken Hague Key Unannounced Inspection 1st November 2006 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rayleigh House DS0000002407.V316610.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. Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rayleigh House Address 17 Derby Avenue Skegness Lincs PE25 3DH 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) 01754 764382 01754 762525 Mr B M Ghent Mrs S Ghent Mrs Susan Hinton Care Home 15 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (15) Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old age, not falling with any other category (OP) (15) Dementia - over 65 years of age (DE(E)) (3) Mental Disorder, excluding the category LD, (MD(E)) (1) The category of MD(E) is on a named basis and will cease when that person is no longer accommodated at the home. The maximum number of service users to be accomodated is 15. Date of last inspection 18th November 2005 Brief Description of the Service: Rayleigh House is a privately owned care home for older people. It is operated as a family run business together with another home in the resort town of Skegness. The home has been converted from a former hotel and has been extended and altered to provide care and accommodation for up to 15 people in 9 single and 3 double rooms Three of the single rooms have en-suite facilities. Accommodation is provided on two floors and a stair lift provides access to the first floor. The home is located in a residential area which it is situated is a cul-de-sac affording the home some quietness and privacy in a busy coastal town. There are shops available in the vicinity and the main shopping area can be reached, however, transport is advised. The home does not have a garden but a sun lounge come small conservatory to the front of the building, allowing residents the opportunity to sit and observe passers by and acknowledge their neighbours. On street parking is available. There are opportunities for the residents of Rayleigh House to enjoy the facilities offered by its sister home. There is a bus stop at the end of the road. Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. A tour of the premises was undertaken. The registered manager was provided with feedback at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents and related care practices. A sample of care records, were inspected. A member of staff was interviewed and the opinions of four residents were sought. A pre-inspection questionnaire was supplied by the care home to the Commission for Social Care Inspection prior to the site visit being made. The Commission received 6 resident’s feedback forms (“have your say documents”) from residents at the care home. These forms asked residents 12 questions regarding services provided by the care home. All of these forms were analysed and their contributions are included in this report. The Inspector was shown quality assessment forms completed in February 2006 in which residents gave opinions to the proprietor of the services provided by the care home. These views are represented within the report. The registered manager makes available to all potential new residents a copy of the statement of purpose of the care home when they visit the home for the first time. A copy is displayed in the care home reception area. A copy of the last Commission for Social Care Inspection report is included in the statement of purpose. The home charges, a range of fees from £335 to £415 per week. What the service does well: What has improved since the last inspection? The registered manager confirmed that residents are now given a copy of the service users guide when they come to stay in the home. Residents individual terms and conditions now include the contribution they pay towards their stay in the care home. The registered manager confirmed staff continue to be Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 6 trained in the administration of medication and that she is confident that the medication policy the care homes is being followed by all staff. A quality assurance system has been introduced by the care home. There is evidence of ongoing maintenance being carried out to the building. A record is now being kept to demonstrate tests are being carried out on a weekly basis for the fire alarm. 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. Rayleigh House DS0000002407.V316610.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 Rayleigh House DS0000002407.V316610.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): Standards 1,2,3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A detailed assessment, which includes a risk assessment, is carried out before any new resident is admitted to the care home. An intermediate care service is not offered by the care home. The home supplies residents with details of the cost of their stay at the care home. EVIDENCE: The registered manager stated that all residents receive a full assessment before being admitted to the care home. The files or three residents sampled as part of this inspection as part of the case tracking process all contain the full assessment carried out prior to admission. Residents files contained copies of the terms and conditions for their stay at the care home which included their individual financial contribution. The registered manager confirmed that a specialised intermediate care service is not being provided by the home. Rayleigh House DS0000002407.V316610.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): Standards 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home identifies the health, personal and social cares needs of each resident and records them on their care plan. This enables staff to meet their needs in a manner, which is described within the individual’s care plan. The medication policy of the home is being followed. Staff respect the dignity and privacy of residents. EVIDENCE: The individual care plans of three residents were studied and discussed with the registered manager and a member of staff. The registered manager and member of staff were able to describe in details the three residents needs. The care plans themselves contained the identified needs of the individual residents and stated how these would be met by the resources of the care home. Risk management was included where any risk had been identified. Details of health care needs were recorded visits by GPs, district nurses and Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 10 chiropody were recorded. The “Have your say” documents completed by residents provided evidence that in their opinion, their needs including health care needs were being met by the care home. The registered manager stated that staff had been trained in the administration and storage of medication. She confirmed the homes medication policy was being followed. Care of plans included the choice and wishes of individual residents in respect of the manner that personal care should be provided by staff. Staff were able to describe the wishes and choices of the individuals being case tracked as part of the site visit. The last three inspection reports state staff treat residents with respect and their privacy is upheld. The observations and discussions with the staff carried out during the visit in November 2006 confirmed that this is still the case. This judgment was supported by comments in the quality assurance forms filled in by residents for the home and in the “have your say” documents returned to the Commission for Social Care Inspection. Rayleigh House DS0000002407.V316610.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): Standards 12,13,14,&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to keep in contact with their family and friends. All visitors are made welcome by staff at the care home. Catering arrangements for the home reflects the resident’s choices, preferences and personal dietary needs. EVIDENCE: Residents stated at the site visit that relatives and friends come to visit them and are made welcome. The details of activities provided for residents were found in the activity folder. The “have your say” documents supplied by residents confirmed that activities do take place which meet the needs of residents. Activities take place within the home and within the community. Residents stated that they go out into the community for events and on occasional outings. Residents stated in a general discussion that they feel they have control over their individual lives. The registered managers provide details of the home’s menu as part of the pre-inspection information. “Have your say” documents provided evidence that residents are satisfied with the Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 12 menu and that their individual dietary needs are being met by the care home. A resident commented in a “the food is very good”. The majority of residents who commented on the menu stated that they were always satisfied with the meals which they stated offers choice to all residents. The individual dietary needs likes and dislikes of residents was found recorded on their individual care plans. Rayleigh House DS0000002407.V316610.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): Standards 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home listens to resident’s views and wishes and acts on them. They are procedures in place to protect residents from any possible abuse. Staff have received appropriate training to protect residents from being harmed EVIDENCE: Staff are being trained in the recognition and management of the abuse. There are procedures and policies in place to ensure that appropriate action is taken should anyone report any suspicion of abuse to the registered manager or the proprietor. Resident stated in “the have your say” document that they are able to raise any issues with any member of staff. Residents state they feel safe living in the care home. There have been no complaints received by the home in the last 12 months. There have been no complaints received by the Commission for Social Care Inspection in the last two years. No investigation has been carried out in respect of suspicion of abuse or poor care practice. The home has therefore acted appropriately to protect residents and ensure they live in a safe environment. The registered manager has acted to ensure that residents can raise concerns with any member of staff. These standards have therefore been continuously over the last two years. Rayleigh House DS0000002407.V316610.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): Standard 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, homely, clean environment with a choice of communal areas and personalised bedrooms. The infection control policy of the home is being followed. EVIDENCE: A tour was made of the care home, all areas were very clean and smelt fresh. There was evidence of ongoing maintenance being carried out. Residents spoken to confirmed their total satisfaction with the environment of the care home. The bedrooms viewed during this visit had furniture and fittings, which met the National Minimum Standards. The proprietor has carried out the follow work since last inspection. The Declaration of bedrooms 10 & 11 and new carpets fitted. Repairs to the paved area round the fire escape. The kitchen Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 15 and laundry have been redecorated. Repairs carried out to the roof above the porch. One lounge has been redecorated, new carpets have been fitted to both lounges halls and stairs. Rayleigh House DS0000002407.V316610.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): Standards 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff on duty with appropriate skills to meet the needs of residents. The home has a robust recruitment policy which protects residents. Training is being provided to staff, resident’s needs are being met. EVIDENCE: Resident’s feedback forms indicate that they are satisfied with present staffing levels. Pre- inspection information supplied by the home demonstrates that staff, are being trained appropriately. Staffing rotas demonstrate that staff, are on duty in sufficient numbers at all times. Training records provided evidence that, 50 of staff have now achieved NVQ 2 or above. The registered manager has completed a staff training programme for the next 12 months. This was seen during the site visit. The “have your say” documents provided evidence that residents feel safe living in the home and staff are available at all times to provide care. There have be no complaints or concerns raised about staffing levels or staffing issues in the last two years. Notifications of incident demonstrate that staff, are managing any problem within the home appropriately. The registered manager confirmed that she follows the home’s recruitment policy. She stated Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 17 all of the appropriate information required is obtained before new member of staff is offered employment. This standard has been continually met over the last two years Rayleigh House DS0000002407.V316610.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): Standards 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and supportive registered manager. staff have been provided with training, supervision and appraisals as required by the Care Home Regulations. The recruitment policy of the home is being followed. The staffing rota ensures that there are always sufficient numbers of staff with appropriate training on duty at all times. The safety and welfare of residents is being promoted by the management. EVIDENCE: The registered manager stated that the home has policies in place for the protection of resident from any potential abuse. The procedures manual Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 19 contains a health and safety and an infection control policy. Staff confirmed that they were aware of these policies. There were no health and safety issues identified at this inspection. A resident stated “staff are very good Im very satisfied with the support they give me”. Other residents who completed a “have your say” document commented that “the home is always clean and it always smells clean. The home, staff and management are excellent”. One resident stated “I am very happy here all my needs are met”. The discussions with members of staff during the site visit produced evidence that good teamwork takes place. Staff stated we work well as a team we can discuss any issues as they arise. The management of the home are very supportive and listen to the views of the residents and staff. The inspector’s judgement is that the home benefits from positive leadership provided by the registered manager. Rayleigh House DS0000002407.V316610.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 3 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? no 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. Refer to Standard Good Practice Recommendations Rayleigh House DS0000002407.V316610.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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