Inspection on 21/06/05 for The Wedge

This inspection was carried out on 21st June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Wedge 26/09/06

The Wedge 20/09/05

The Wedge 04/01/05

The Wedge 07/07/04

The Wedge 19/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Wedge 8 Park Road Hayling Island Hampshire PO11 0JU Lead Inspector Nick Morrison Unnannounced 21.06.05 10:00 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 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. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Wedge Address 8 Park Road Hayling Island Hampshire PO11 0JU 023 9246 5225 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Monica Joy Macey Miss J Macey Care Home 15 Category(ies) of Old Age - OP - 15 registration, with number of places The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18.01.05 Brief Description of the Service: The Wedge is a large, detached building set in a quiet residential area of Hayling Island. Accommodation is provided for by way sixteen single bedrooms, fourteen of which have an en-suite facility. Day space is provided for by way of three day rooms and there are attractive, well-maintained gardens to the front and rear of the building. The home is in good decorative order throughout and provides service users with a comfortable, friendly environment. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 9.00am on 21/6/05 and lasted for four hours. During this time the Inspector spoke with staff and service users, toured the premises and looked at records. The Manger was training on the day of inspection and the Inspector returned to the home to meet with her on 23/6/05 to complete the inspection. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements or recommendations made as a result of this inspection and the Proprietors and Manager are continuing with the process of trying to improve the service in response to the views of service users. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 6 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 Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 standard(s) 1 and 3 Standard six was not applicable to this service. Service users have the information they need about the service to make a choice about living there and have their needs assessed prior to admission to ensure the home can meet these. EVIDENCE: The Inspector looked at the file for the most recently admitted service user and found that the pre-admission assessment was fully completed and the file contained all the necessary information. Staff had begun the process of developing a care plan for this person in relation to the assessment and the additional information they had found out about her since her admission. There was a Service User Guide and Statement of Purpose available that provided adequate and useful information about the home and strongly promoted the rights of service users. In addition, the home has a Charter of Rights, which is made available to all service users and their families and is displayed in the entrance hall. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 Service users’ needs are met and they are protected by the home’s medication policies and practices. EVIDENCE: The Inspector saw Care Plans on file for each service user. These had been written in response to the initial assessment, the information the home had gained about each person while they had lived in the home and the changing needs of service users. Service users were aware of their Care Plans and they were reviewed on a monthly basis. The plans also contained risk assessments for activities where an element of risk had been identified. Service users’ files contained documentary evidence that their healthcare needs were monitored on a regular basis and that they were supported to access healthcare services as necessary. On the day of inspection the District Nurse was visiting some service users at the home. The home has a policy in place for self-administering of medication that necessitates a risk assessment being in pace for any service users who wish to control their own medication. Some service users did administer their medication and had locked space in their bedrooms to store it in. Where the home administered medication for service users, there were adequate, accurate and up-to-date records kept and the medication was stored The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 10 appropriately and safely. Staff involved in handling medication had all had training in the safe handling of medication and this had recently been updated. Service users spoken with during the inspection all felt that they were treated with respect by all staff and that their privacy was upheld. All service users spoken with were very positive about the staff who supported them. Comments included “the staff are lovely”, “I couldn’t fault it here at all” and “you’ve only to ask and you get what you want”. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Service users benefit from being able to maintain contact with their friends and families and from having control of their own lives. They also benefit from a good diet and stimulating activities. EVIDENCE: Activities for service users were planned in response to the known interests they have and details of these were posted in the building. There were additional activities planned such as days out to the pub or shopping. These were posted on the notice board and service users were able to put their names down if they wished to attend. Service users spoken with had really enjoyed a recent visit to the pub for lunch. There is a Visitors’ Policy in place that encourages friends and relatives to visit at any time but to ring in advance if they were going to be visiting late or if they wanted to speak to the Manager or a particular member of staff. The policy is on the wall in the entrance hall. Service users are able to have telephones in their own rooms to enable them to keep in touch with their families and friends. Service users spoken with said there were no problems with keeping in touch with people or having visitors and that visitors were always made to feel very welcome in the home. Service users spoken with also said that they were happy about the amount of choice and control over their own lives they were able to exercise. The home The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 12 hs policies, the Service User Guide and the Charter of Rights in place to promote this and staff observed on the day of inspection interacting with service users did so in a way that encouraged and supported service users to be independent and to make their own choices. The Inspector looked at menus, which appeared to offer a balanced and nutritious diet. Service users spoken with were very complimentary about the quality of food in the home and said that portions were more than adequate. At present, there are two sittings at mealtimes because of the limited size of the dining room. However, the Proprietors are planning to extend the dining room in the future. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Service users benefited from clear information on how to complain and were protected by the home’s policies and practices. EVIDENCE: The home’s Complaints Policy now includes timescales within which complaints will be responded to. The policy is available to all service users and their families and some service users spoken with were aware of it. There was a system in place for recording all complaints and the responses to them but no complaints had been received. The home provides information to service users and their families about local advocacy services and also makes this information available on the notice board in the entrance hall. There is a Whistleblowing Policy in place and policies concerning how to respond to issues of suspected abuse and staff had information on what might constitute abuse. The Manager and Deputy Manager had recently received training on dealing with instances of suspected abuse and were planning to provide training to all staff on the subject. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Service users benefited from living in a well maintained, clean, hygienic and safe environment. EVIDENCE: The home was well maintained and all efforts were made to ensure the environment was safe at all times. All radiators were covered and handrails were available throughout the building. There was a stair lift to enable service users to move safely up and down the stairs and this was maintained regularly and was in good working order. The gardens were kept tidy and safe and on the day of inspection service users were sat in the garden enjoying the weather. Shaded areas were provided. The kitchen was well equipped and kept clean and hygienic, as was the laundry area. All staff had recently received training in Infection Control and the home’s Infection Control Procedures and cleaning schedules were sufficient to maintain good hygiene. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Service users benefit from being supported by adequate numbers of well trained staff and were protected by the home’s employment policies and practices. EVIDENCE: The home’s rotas were clear and provided sufficient staff for the needs of service users. On the day of inspection there were five staff on duty and this accurately reflected the planned rota. Service users spoken with were positive about the amount of support available to them. Staff files showed that all necessary checks were made on new staff before they began working in the home. The amount of staff training had increased over the last year and the Manager had a planned response to the training needs of the people working in the home. Needs were identified on an ongoing basis and through the Annual Appraisal system. Support and supervision sessions were being increased from every three months to every two months. Three staff were currently undertaking NVQ2 in care with a further three due to begin this training. One member of staff had just completed her NVQ3 and another was just about to start. The Manager and Deputy Manager were in the process of doing the NVQ4. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 Service users’ benefited from being involved in the development of the service and from living in a safe environment. EVIDENCE: Since the previous inspection the home had undertaken a survey of service users’ views of the home. This had taken place in May 2005 and service users were supported by their families to participate in the survey. The survey covered all aspects of the service for service users to comment on. The responses given by service users were generally positive. The Manager collated the results and planned responses to issues raised where the service could improve. This was put into an action plan that was then shared with service users and their families through a newsletter that they all had a copy of. The Manager plans to continue producing a newsletter to keep service users and their families informed of developments in the service. Health and safety issues were given a priority in the home and all staff were up-to-date with health and safety related training. Suitable policies were in The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 17 place and records showed that regular monitoring checks were made to ensure the home was safe at all times. Good records were kept of all servicing and maintenance of equipment and all risk assessments were up-to-date. Fire procedures were posted throughout the building and were contained in the Service User Guide. Fire instruction for staff was up-to-date and a Fire Maintenance Certificate had been issued on 1/6/05. The home had had an Electrical Safety Check. Since the previous inspection, the hot water in the home had been adjusted so that it is delivered at a safe temperature. The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 19 no Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 20 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 The Wedge H54 S11783 The Wedge V225360 200605.doc Version 1.30 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!