CARE HOMES FOR OLDER PEOPLE
Selkirk Wing Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR3 2XL Lead Inspector
Alison Ford Unannounced Inspection 25th January 2006 11:05 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.V276293.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. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 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.V276293.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 22nd September 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 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. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/2006 and was an unannounced visit, taking place over 2 hours. The acting manager is currently in the process of applying to The Commission for Social Care Inspection for registration and awaiting a date for interview. A partial tour of the premises was undertaken, along with an assessment of a sample of care plans and records kept to ensure the safety of residents. Several of the residents and one relative who was visiting were spoken with and all of the comments made by them, about the care that they received, were positive. Over the course of the year all of those standards considered by The Commission to be key to the inspection process, have been assessed and this report should be read in conjunction with the one issued following the visit on September 22nd 2005. What the service does well: What has improved since the last inspection?
Since the last inspection some bedrooms have been redecorated and supplied with new curtains and bedspreads. Those bedroom carpets, which are especially unpleasant and malodorous, are about to be replaced. Some recruitment procedures are managed centrally by the organisation and not all of the pre-employment checks, needed to ensure the safety of
Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 6 residents, were previously available for inspection. At this visit it was possible to see copies of documents that provided evidence that clearance had been received from The Criminal Records Bureau for employees at the home. A training needs analysis is being completed so that shortfalls can be identified and by the end of the year all staff will have completed all their mandatory sessions. The homes first relatives meeting is about to take place and all of the care plans have been reviewed and updated. Previous visits have highlighted problems with the catering arrangements in place in the home. In order to improve this new menus have been produced and the chef has now increased the meetings that he has with staff to discuss any problems. 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.V276293.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 Selkirk Wing DS0000019120.V276293.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): These standards were not assessed at this inspection. EVIDENCE: Selkirk Wing DS0000019120.V276293.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): 7,8,10 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 EVIDENCE: All residents have an individual care plan developed from their initial assessment and 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 are reviewed regularly. 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. There is evidence that relatives have been asked to contribute to the plans where it has been possible. All personal care is delivered in resident’s own rooms, which are single occupancy, and those spoken with agreed that staff treat them with respect and dignity.
Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 10 Selkirk Wing DS0000019120.V276293.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): 15 Residents can be sure that their views are taken into consideration and the staff are trying to provide a balanced and appealing diet for them. EVIDENCE: Those spoken to said that they always enjoyed the food that was served although some adverse comments had been received previously. Menus have recently been changed and are posted on the wall. Choices are always available and the chef now has regular meetings with the staff and residents to confirm their satisfaction with the food that is served. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 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): 16,18 Residents can be sure that their complaints will be treated seriously and dealt with in accordance with the recognised procedure and that there are processes in place to protect them from abuse. EVIDENCE: A complaints procedure is displayed in the entrance hall. No complaints have been received either by the home or by The Commission since the last inspection. Procedures and policies are in place to protect residents from abuse and there is evidence that all staff have received appropriate clearance from The Criminal Records Bureau. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 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 Much of the home still 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. Residents are still being placed at risk in the event of a fire occurring. 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 still requires redecorating. New carpets are about to be fitted in three bedrooms where they had been especially unpleasant. A previous requirement to fit self closing devices to bedroom doors, where residents wished them to be left open, has still not been complied with and this continues to pose a potential risk to residents in the event of a fire.
Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 14 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): 28,29,30 Residents can be confident that robust recruitment procedures are in place to protect them however; staff training is not always sufficient to ensure their safety. EVIDENCE: Concerns around Criminals Rerecords Bureau clearance have now been resolved and copies of the relevant documentation are being retained for inspection. A training needs analysis for staff is being completed and the manager is confident that staff will have received all their mandatory session by the end of the year. Some of the staff are undertaking NVQ training however the standard of 50 having gained this at level 2 is still not met. The management team will need to submit an action plan outlining how this will be achieved. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 15 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): 33,35,38 Residents can be sure that the home is run in their best interests and that there are procedures in place regarding their health and safety and financial interests which will protect them. EVIDENCE: The first relatives meeting for the home is about to take place and the twiceyearly audit is about to be undertaken. Results of this extensive audit, which looks at all aspects of the care, policies and procedures in the home, will be available to all users of the service. Small amounts of pocket money are held for residents and records of this were seen and were accurate and appropriate. Records of routine maintenances of equipment were seen and were up to date. Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 17 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. 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. (Previous timescale 30/12/05 not met) 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 and 30/12/05not met) 3 OP28 18(1)(c) The Registered Providers are 30/03/06 required to submit an action plan to The Commission for Social Care Inspection outlining how they plan to ensure that at least 50 of staff have an NVQ level qualification at level 2 Timescale for action 30/03/06 2 OP19 13(4)(c) 30/03/06 Selkirk Wing DS0000019120.V276293.R01.S.doc Version 5.1 Page 18 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.V276293.R01.S.doc Version 5.1 Page 19 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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