Inspection on 27/11/06 for Selkirk Wing

This inspection was carried out on 27th November 2006.

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 17/07/07

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 27th November 2006 9:30am 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.V320892.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.V320892.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 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.V320892.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 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 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. The range of weekly fees is between £697 and £730. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It took place over four and half hours. Some times were spent looking at the records, talking to some service users and registered 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. The Commission received a number of positive feedback about the care being provided in the home, however a number of comments were also made that staff do not spend much time talking to service users. This was discussed with the registered manager who gave assurance that she would look into this issue. Two immediate requirements were issued on the day of inspection regarding fire safety not being adhere to, as this could potentially place service users and staff at risk in an event of fire. 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. Selkirk Wing DS0000019120.V320892.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.V320892.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.V320892.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 is able to demonstrate that service users needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a comprehensive needs assessment. The home does not offer intermediate care. Selkirk Wing DS0000019120.V320892.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): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. However the system for administration of medication is poor and potentially place service users at risk. EVIDENCE: A sample of service user care plans was examined and it was evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. There was also evidence from review notes that service users’ care needs are being reviewed on a monthly basis with amendments being made to the service user plans where needs have changed. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 10 The registered manager was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners and other health care specialists as required. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. The optician was visiting the home on the day of the inspection. The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The registered person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. It was noted that the home also carries out a medication administration audit on a regular basis however these omissions have not been identified. The Commission is very concerned as the system for administration of medication is poor and potentially place service users at risk. This issue was discussed in depth with the registered manager. It was also noted that two of service users did not have their allergies written on their MAR sheets, this potentially places them at risk. The registered person must ensure that the allergy section on the medication profiles is complete for all service users. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Service users are always treated with respect and dignity in accordance with the homes statement of purpose. Selkirk Wing DS0000019120.V320892.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): 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. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. Many of the service users within the home are very frail and have limited abilities however they enjoy the sessions currently provided. The home has an activity coordinator in post. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 12 The service users’ comments and observation confirmed that the home is run in a manner that promotes choice and independence. None of the service users manage their own financial affairs. 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. Selkirk Wing DS0000019120.V320892.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): 16 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. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. 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. There has been one complaint since the last inspection and this has been resolved. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. The London Borough of Sutton’s adult protection procedures were available in the office on request. There have not been any adult protection concerns raised. The registered manager informed that most of the staff have had abuse awareness training. Selkirk Wing DS0000019120.V320892.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): 19 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, clean, homely and comfortable however fire safety issue still need to be addressed as this potentially places service users and staff at risk. 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. However the home is not complying with fire regulations (see standard 42). Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 15 The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Selkirk Wing DS0000019120.V320892.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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However there is still a need to ensure that at least 50 care staff are educated to at least NVQ level 2 standard. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. Domestic staff are employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met, and that the home is maintained in a clean and hygienic state. It was previously required that the Registered Providers must 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. The registered manager informed that 47 of staff now have an NVQ level qualification at level 2. This standard has not yet been met and will be reassessed at the next inspection. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 17 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. There is a staff training and development programme in place. The manager is very proactive in respect of staff training. The manager was able to produce documentary evidence of staff attendance of a variety of different training courses that were relevant to the work staff were expected to perform. Selkirk Wing DS0000019120.V320892.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): 31,33,35,36 and 38 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 managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: The manager has been successful at her fit person interview with the Commission and is now the registered manager for the home. She stated that she has recently completed her NVQ level 4 and Registered Manager’s Award. She also undertakes periodic training. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 19 Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. The manager informed that small amounts of money are kept in separate envelopes for each service user with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and it was noted that two of the balances did not match what was in the envelope. 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. During the inspection it was noted that one fire door was propped open by a door mat. The registered provider must ensure that all fire doors are kept shut unless held by a device that shuts the door automatically in the event of a fire. The Commission is also concerned about the lack of security in the home. On the day of the inspection the front door was unlocked. There is a clear sign stating that the door must be kept locked. The inspector was able to gain access to the building without being challenged by a member of staff who was walking in the corridor. The home looks after vulnerable people and the registered provider is failing to ensure that the service users and staff are safe at all times. The registered provider must ensure that the health, safety and welfare of service users and staff are promoted and protected at all times. Records of routine maintenances of equipment were seen and were up to date. However it was noted that the service certificate for the fire extinguishers was expired (end of October 2006). The registered provider must ensure that all fire extinguishers are maintained at regular intervals that is yearly. Selkirk Wing DS0000019120.V320892.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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 30 X 3 3 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 X 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 21 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 registered person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. The registered person must ensure that the allergy section on the medication profiles is complete for all service users. The registered provider must ensure that 50 of staff have an NVQ level qualification at level 2. 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. Timescale for action 27/11/06 2. OP9 13(2) 30/11/06 3. OP28 18(1)(a) 31/03/07 4. OP35 Schedule 4(9) 27/11/06 5. OP38 13(4)(c) The registered provider must 27/11/06 ensure that all fire doors are kept shut unless held by a device that shuts the door automatically in the event of a fire. Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 22 6. OP38 13(4) The registered provider must ensure that the health, safety and welfare of service users and staff are promoted and protected at all times (security of the premises). The registered provider must ensure that all fire extinguishers are maintained at regular intervals that is yearly. 27/11/06 7. OP38 23(4)(c) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 23 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 Selkirk Wing DS0000019120.V320892.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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