CARE HOMES FOR OLDER PEOPLE
Selkirk Wing Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR3 2XL Lead Inspector
Alison Ford Unannounced Inspection 22nd September 2005 10:00 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 Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 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.V250699.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Selkirk Wing Address Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR3 2XL 020 8660 7656 020 8668 6411 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 Elderley 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.V250699.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th March 2005 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 care for up to twenty elderly people who require nursing care. It is part of a large property set in secluded well-maintained 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. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/2006 and was an unannounced visit, taking place over 2 3/4 hours. Although the manager has worked within the home for a few months, she has only been in this role for the last three weeks and is currently in the process of applying to The Commission for Social Care Inspection for registration. With this in mind and recognising a previous good standard of care within the home this visit concentrated on a partial tour of the premises, assessment of a sample of care plans and talking to the majority of the residents. One newly appointed member of staff was also spoken to, about the information that they had provided prior to their employment, their induction programme and their perceptions of the home. Standards applying to these areas were inspected and others will be reviewed at a further visit later in the year. Prior to the inspection comment cards had been received from ten residents, one relative and the GP who attends the home. The majority of replies were favourable however; some adverse comments were received, about the lack of continuity in the management structure and it is hoped that an improvement will be seen at the next inspection in relation to this. What the service does well: What has improved since the last inspection?
Since the last inspection, there has been restructuring of the management team with the new manager appointed to the home within the last three weeks. She is now in the process of reviewing standards of care and resident’s individual care plans and these will be assessed in greater depth at the next visit.
Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 6 A previous reliance on agency staff has now been reduced with the appointment of more permanent and bank staff and there are no vacancies now remaining. A rota is also now in place to ensure that all staff always have access to a senior member of staff in an emergency. 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. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 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.V250699.R01.S.doc Version 5.0 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): 3,6 A pre-admission assessment, undertaken by a senior member of the nursing staff, ensures that residents can be confident that the home will be able to meet their needs. This home does not offer intermediate care. EVIDENCE: The assessment tool used prior to admission was seen in the care plans that were assessed. It was comprehensive and took note of both physical and psychological needs. It included risk assessments, continence assessments, and information about medication, residents past lives, their hobbies and interests. This assessment then forms the basis for subsequent care planning. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 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): 7,8,9,10 Individual care plans ensure that residents care needs are identified and met and arrangements for personal care are in place so that dignity and privacy are maintained. Appropriate medication policies are in place to protect resident’s wellbeing. EVIDENCE: All residents have an individual care plan developed from their initial assessment and in the majority of cases this reflects the care that is currently being given. All residents are allocated a named nurse and key worker who have responsibility to keep these up to date and they will then be reviewed monthly by the manager. She is aware that some of these still require updating and is currently undertaking this task. Care plans illustrate that there has been access to other members of the multidisciplinary healthcare team and show that regular monitoring is undertaken to identify those at risk of developing pressure sores. Trained nurses administer all medication in the home, medication stores and records were seen to be in good order and new procedures are in place for the disposal of medication in line withy current policy. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 10 Personal care is delivered in resident’s own bedrooms all of which are single occupancy and staff were observed to be treating them with respect and dignity. Residents confirmed that staff were always kind and pleasant to them and all of them looked well cared for. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 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 Visitors are always welcome to the home so that relationships with family and friends are maintained. Activities within the home are being increased to suit the needs of residents and they are encouraged to make choices in their daily lives where possible in order to maintain their independence. EVIDENCE: Previous comments have been made, by residents and relatives, regarding a lack of stimulation within the home and money has now been made to increase the provision of structured activities. Many of the residents within the home are very frail and have limited abilities however they enjoy the sessions currently provided. Visitors are always welcome in the home and church representatives visit frequently and are much appreciated. Residents would be encouraged to make choices where they were able, such what they eat and wear however their frailty means that they appreciate a structured environment. Those spoken to said that they always enjoyed the food that was served although some adverse comments were received from relatives. The new manager now has the ingredients to make supplementary drinks for those with poor appetites. Menus are posted on the wall and choices are always available.
Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed at this inspection. EVIDENCE: Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 13 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): 19,26 Much of the home requires redecoration in order to provide a comfortable environment for residents and carpets require replacing to make it a clean and pleasant place to live. EVIDENCE: The home is within an attractive building surrounded by farms and woods and it is reached via a private road. The grounds are well maintained and accessible with areas of lawn and flowerbeds. The home is furnished in an appropriate and homely style however much of it requires redecorating. Several carpets and the bathroom floor need to be replaced; two bedroom carpets are especially malodorous and unpleasant and must be replaced without delay. An action plan detailing how these issues will be addressed needs to be submitted to The Commission. A previous requirement to fit self closing devices to bedroom doors, where residents wished them to be left open, has not been complied with and now must be addressed promptly. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 14 Inspections have recently been undertaken of fire fighting equipment and it was noted that some extinguishers were required to be replaced, apparently to come into line with new legislation. The manager is required to submit evidence that these extinguishers are safe to be in place until that time. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 15 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): 27,29 Staffing levels within the home are appropriate to ensure that the healthcare needs of the residents are met however; evidence is not always available to verify that they are always protected by recruitment procedures. EVIDENCE: Staffing rotas were supplied which verified that there are always sufficient numbers of staff on duty. Previous inspections had found a reliance on agency workers, which has now been addressed by the appointment of additional staff. One newly appointed member of staff was spoken to and confirmed that necessary checks and documentation had been requested prior to his starting work. Examination of the relevant staff file showed that there is not always documentary evidence of clearance from The Criminal Records Bureau and Protection of Vulnerable Adults Register and it is held centrally. This must be available in the home for future inspections. There was evidence that recent fire training had occurred. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 16 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): 31 Residents are confident that they live in a home that is run by a person that is experienced fit to be in charge and will maintain their safety. EVIDENCE: The new manager of the home has experience of managing another establishment and is currently in the process of applying to The Commission for registration. Several residents commented on her kindness. The pre-inspection questionnaire indicated that all facilities and equipment used within the home has been serviced and maintained as necessary and this will be checked at the next inspection. Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 17 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 x 3 x x N/A 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 x 17 x 18 x 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x x Selkirk Wing DS0000019120.V250699.R01.S.doc Version 5.0 Page 18 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 OP19 Regulation 23(2)(b) Requirement The Registered Providers are required to submit an action plan to The Commission for Social Care Inspection outlining how they plan to continue the redecoration of the home. The Registered Providers must replace the worn bathroom floor The Registered Providers must replace the malodorous bedroom carpets. The Registered Providers are required to put self-closing devices on bedroom doors so that they shut automatically in the event of a fire. (Previous timescale of 30/6/05 not met) The Registered Providers must supply The Commission for Social Care Inspection with evidence that CO2 extinguishers within the home are still safe to be used until such time as they are replaced with new ones to comply with new legislation. The Registered Providers must ensure that there is evidence that staff have received
DS0000019120.V250699.R01.S.doc Timescale for action 30/12/05 2 3 4 OP19 OP19 OP19 23(2)(b) 16(2)(k) 13(4)(c) 30/12/05 30/10/05 30/12/05 5 OP19 13(4)(c) 30/10/05 6 OP29 19(5)(d) 30/12/05 Selkirk Wing Version 5.0 Page 19 clearance from the Criminal Records Bureau and POVA register available for inspection. 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.V250699.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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