Inspection on 17/07/07 for Selkirk Wing

This inspection was carried out on 17th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Selkirk Wing 16/07/08

Selkirk Wing 27/11/06

Selkirk Wing 25/01/06

Selkirk Wing 22/09/05

Selkirk Wing 14/03/05

Selkirk Wing 10/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Selkirk Wing Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR5 2XL Lead Inspector Mohammad Peerbux Key Unannounced Inspection 17th July 2007 9:00am 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 Selkirk Wing DS0000019120.V345991.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. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selkirk Wing Address Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR5 2XL 020 8660 7656 020 8668 6411 manager@selkirk.fote.org.uk 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) Friends of the Elderly Ms Susan Guyon Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Terminally ill over 65 years of age (0) of places Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2006 Brief Description of the Service: Selkirk Wing is the nursing wing of Woodcote House and is situated in Coulsdon and owned by the registered charity Friends of the Elderly. It is registered by The Commission for Social Care Inspection to provide nursing care for up to twenty elderly people. It is part of a large property set in secluded wellmaintained grounds and surrounded by paddocks and woods. The grounds are over forty-five acres and include flowerbeds, lawns and patio areas. Adjacent to the home is a golf club with a clubhouse. The home is accessed by a private road and there is ample car parking. Accommodation is provided on the ground floor and communal facilities include a lounge with a dining area, hairdressing room and a chapel. The home is situated a few miles from local transport and shopping facilities. The range of weekly fees is between £732 and £767. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This was the home’s first inspection for the year 2007/08. It took place over five and half hours. Some times were spent looking at the policies and procedures, records, talking to some residents, staff and manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. What the service does well: What has improved since the last inspection? The administration/non-administration of all medication is now being recorded accurately. All fire doors are being kept shut unless held by a device that shuts the door automatically in the event of a fire. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Selkirk Wing DS0000019120.V345991.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 Selkirk Wing DS0000019120.V345991.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes a comprehensive assessment of the healthcare needs of service users prior to their admission and regularly reviews these to ensure that they continue to be met. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a care management assessment, then the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 9 conducted professionally and sensitively and has involved the family or representative of the resident. Intermediate care for rehabilitation and return to the community is not provided by this home. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally residents’ personal, physical and emotional health needs are being met and reviewed. EVIDENCE: The home has a strong belief that it is essential to involve residents as far as possible in the planning of care that affects their lifestyle and quality of life. Residents have a plan that has been agreed with them where they are able to do so. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment. Areas have been identified where staff are willing to support residents to take some risks, which may have an impact on their rights. Evidence of updating information and changing actions Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 11 appears in the care plans however the home is reminded that this should be done on a monthly basis. The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit frail residents in the home and provides facilities to carry out treatment. Presently none of the residents have pressure sores however the tissue viability nurse is in regular contact with the home to advise them accordingly. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. The home has worked towards improving the medication systems, as there were concerns raised before with regards to the administration of medication. However it was noted that a number of prescribed dressings was out of date. The home must ensure that all item of medication are within their use by date so that residents are not put at risk. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “I am happy here and the staff look after me well, I do not have any concern”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 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 being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. There is a chapel service every Thursday and Sunday. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 13 The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. It is clear that the home encourages individuals and groups from the community to visit the home. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The cook consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 14 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): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The home’s aims and objectives include the rights of residents. Residents are supported to live as independently as possible, exercising their rights to make choices and decisions with assistance when needed. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. Most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedroom are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 16 During a tour with the registered manager, the call bell was activated on two occasions in two separate rooms and no staff member responded to the call. This is very concerning to the Commission as this poses a potential risk to residents. This was discussed in depth with the registered manager and staff nurse on duty. They both stated that it was not acceptable and would discuss this further with the staff on duty. The home is always very well lit, clean and tidy and smells fresh. The management has a proactive infection control policy and they work closely with external specialists, e.g. infection control, and their own staff to ensure that infections are minimised. Clinical waste is properly managed and stored. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. The home’s recruitment procedures protect the residents through vigorous staff vetting. EVIDENCE: Resident spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Four staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 18 The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The home is also able to recognise when additional training is needed, and attempts to plan over time to provide this training. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home management generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a good equality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: The registered manager has the required experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents. There is a strong ethos of being open and Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 20 transparent in all areas of running of the home. The registered manager is resident focused and leads and supports a strong staff team. She is also aware of current developments both nationally and by CSCI and plans the service accordingly. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. It was previously required that the registered manager must ensure that residents’ financial interests are safeguarded at all times and that accurate records are kept as far as their spending money is concerned. A sample of the residents’ spending money was seen and it was noted that two of the balances did not match what were in the envelope and therefore this requirement would be repeated. From staff files sampled at random there were evidence that care workers are being supervised on a regular basis. General residents’ documentation is held in the staff office on the ground floor of the home, however the door is not kept lock when no staff are present. The registered manager must ensure that confidential information relating to residents and staff are stored safely and confidentially and access should be limited to only those who need to know. The home has a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements and has an action plan for undertaking the work. Certificates relating to health and safety were up to date servicing certificates. Records are of a good standard and are routinely completed. The home is reminded to ensure that the hot water temperature is within recommended level of 43 degrees centigrade. Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 2 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 2 3 2 3 Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement The home must ensure that all item of medication are within their use by date so that residents are not put at risk. The home must ensure that all call bells are responded to accordingly so that residents are not put at risk. The registered manager must ensure that service users’ financial interests are safeguarded at all times and that accurate records are kept as far as their spending money is concerned. (Previous timescale 27/11/06 not met) Confidential information relating to residents and staff must be stored safely and confidentially and access should be limited to only those who need to know. Timescale for action 17/07/07 2. OP22 13(4)(c) 17/07/07 3. OP35 Schedule 4(9) 17/07/07 4. OP37 17(1) 17/07/07 Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 23 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 Selkirk Wing DS0000019120.V345991.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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