Inspection on 19/07/06 for Wainfleet Care Home

This inspection was carried out on 19th July 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 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

Wainfleet Care Home 09/07/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Wainfleet Care Home Rumbold Lane Wainfleet Lincs PE24 4DS Lead Inspector Wendy Taylor Key Unannounced Inspection 19th July 2006 08:45 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 Wainfleet Care Home DS0000066378.V304667.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. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wainfleet Care Home Address Rumbold Lane Wainfleet Lincs PE24 4DS 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) 01754 881155 01754 881494 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Miss Jill Lawie Care Home 43 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (43), Old age, not falling within any other of places category (5) Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care to service users whose primary needs fall within the following categories:Dementia - over 65 years of age (DE/E) - 43 - both sexes Old Age, not falling within any other category (OP) - 5 - both sexes The maximum number of service users to be accommodated is 43. Five beds in the category of Old Age, not falling within any other category (OP) applies to service users named in the proposal to register dated, 2nd June 2005. 27 January 2006 2. 3. Date of last inspection Brief Description of the Service: Wainfleet Care Home is a two storey, purpose built property situated close to the town centre and church. The home predominantly provides services to people who have dementia, although there are five beds available for named people who do not have dementia. The upper floor is accessed by stairs and a passenger lift and it is a secure area, which caters for those people who may be at risk of injury from using stairs or leaving the building without support. Bedrooms cater for single occupancy, with the exception of four twin rooms. There is a small enclosed garden to the rear of the building and a small patio area at the side of the building, both of which are accessible to residents. There is limited parking at the side of the home. The current fees for the home range from £379:00 to £480:00 per week. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during July 2006 and the visit to the home was carried out over approximately six hours on one day. The support received by four residents was followed in detail. Feedback was obtained from these people and others who live at the home. Individual resident’s records and general house records were looked at; staff and the registered manager were spoken to and observation of the support provision was made. Residents said that they were very happy living at the home and they liked the food and their bedrooms What the service does well: What has improved since the last inspection? What they could do better: The home maintains a good quality of care. Issues were discussed with the registered manager relating to liaison with GP’s, increasing details in care plan review records and maintaining a regular monitor of staffing levels. These issues have been referred to in the main body of the report. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 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. Wainfleet Care Home DS0000066378.V304667.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 Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents benefit from a robust assessment process and are assured that the home can meet their needs. EVIDENCE: Pre admission assessments are on individual files and they demonstrate that relevant professionals, families and the resident, where they are able, are involved in the process. The registered manager said that she is currently revising the format for confirming that the home can meet people’s needs prior to admission. Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. There are comprehensive care plans and risk assessments in place that ensure resident’s needs are met and their privacy and dignity are maintained. Medication administration procedures generally safeguard residents but there could be more liaisons with general practitioners. EVIDENCE: Care plans are detailed and include needs such as personal care, personal safety, pressure area care, end of life wishes and arrangements, dental care, dementia and self-image. They also reflect dignity, choice and independence. There is a resident’s charter on display in the entrance hall, which clearly refers to maintaining privacy and dignity for residents. Staff were observed to be attentive and respectful towards residents throughout the visit. Records demonstrate that care plans are reviewed but they do not provide a great deal of detail about the review process. The registered manager said that she would discuss this issue with staff and ensure that more detail is recorded. Risk assessments are available in individual files for areas such as nutrition, falls, skin integrity, and moving and handling. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 10 There is an update in the current newsletter to residents and relatives about how fluid and diet intake and slips, trip and falls are managed within the home. The newsletter is available in the entrance hall. A new file format for residents is currently being introduced, but previous formats remain in use until new ones are complete. The registered manager said that the target date for completion of the transfer is 31 August 2006. Medication administration procedures and records were satisfactory and there is up to date information about medicines available for staff reference. The registered manager said that staff no longer carry out blood glucose monitoring, as District Nurses are unable to provide training and assess competence. There are risk assessments in place for each resident who is diabetic and the registered manager said she would liaise with the relevant GP’s to discuss possible alternatives. The registered manager also said that she would also liaise with the relevant GP’s in regard to developing the systems of identifying when to give ‘when necessary’ medication in a consistent manner if the person is unable to clearly indicate the need for such e.g. pain control. Records demonstrate that a medication audit is carried out monthly. Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents benefit from having a balanced and wholesome diet, and a wide range of social and recreational activity. EVIDENCE: Care plans relating to recreation and social needs are completed by the activity co-ordinator and are available on resident’s files. Residents said that they have a good choice of activity and records show that fancy dress parties, trips to town, baking, sewing and bingo are on offer. There are photographs around the building of residents engaging in the activities. The activity programme for July 2006 is displayed in the entrance hall and there is an invitation in the monthly newsletter for residents and relatives to give input to activity planning. Residents said that the food is very good, and that they always get a choice. They said that they always get a cooked breakfast if they want one and several residents had chosen this option on the day of the visit. Meals were well presented, choices were given and the atmosphere during the meal times was relaxed. Residents said that in general they can choose what they want to do and staff will help them to decide things if they ask them to. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 12 Wainfleet Care Home DS0000066378.V304667.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Residents are protected by comprehensive policies and procedures, and staff understand the reporting procedures for adult protection issues. EVIDENCE: There is a copy of the complaints policy on display in the entrance hall and in the service user guide, which is located in individual bedrooms. There is also an adult protection policy available, including local authority guidance. The Commission has received two complaints about the home since the last inspection, both of which have been responded to by the registered manager in accordance with policy; both were upheld. Residents said that they know how to make a complaint and that they would talk to the registered manager. One member of staff had limited knowledge of adult protection issues but knew how to report any suspicion or observation of such. The manager provided evidence that training was scheduled to take place during the week following the inspection visit. Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home is safe, well maintained, clean and tidy; and offers an environment that enables residents to maintain as much independence as possible. EVIDENCE: On the day of the visit the home was clean, tidy and there was no unpleasant odours. In the upstairs area of the home, bedroom doors are painted in bright colours and have personal pictures displayed on them to help residents recognise which room belongs to them. In communal areas there are wall mounted touch boards, photographs of residents and their families and photographs of residents engaging in activity which help the resident with recognition and memory recall. Bedrooms are personalised and comfortable And residents and their relatives are provided with an update regarding the decorating programme for the home by way of the current newsletter. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 15 Residents said that there still needs to be more light in the lounge for sewing but they knew that the registered manager has ordered new lighting; the registered manager provided the order form as evidence of this. A new process of monthly kitchen audits are now in place and the audit reports are held in the quality assurance file. Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. Current recruitment procedures and training programmes safeguard residents, and at present their needs are met by adequate numbers of staff. EVIDENCE: The current newsletter provides an update for residents and relatives about the staff who work in the home and their responsibilities. Staff said that there are enough people on duty to meet individual needs at the present time. The general atmosphere within the home was relaxed and calm and call bells were answered promptly. The home is not fully occupied at present and the issue of ensuring appropriate staffing levels for increased resident numbers was discussed with the registered manager, who said that she would ensure that staffing levels are regularly monitored. Staff said that there is a good induction and training programme, which includes health and safety issues, company policies and procedures and care plan orientation. An individual induction session was being conducted on the day of the visit. Records demonstrate that staff have received training in National Vocational Qualification Level 2 and/or Level 3, fire safety, moving and handling, basic food hygiene, health and safety, first aid, Control Of Substances Hazardous to Health (COSHH) and medicine administration. The registered manager said that dementia awareness training is planned for 2006. Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 17 Staff recruitment records were satisfactory and contained the necessary information. Wainfleet Care Home DS0000066378.V304667.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. The home is well managed and the resident’s health and safety needs are generally promoted. EVIDENCE: Records demonstrate that staff receive regular supervision and staff confirmed this during discussions. They also said that they receive good management support. Fire drill instructions are reiterated for residents and relatives within the current newsletter, as is a request for large amounts of money and valuables to be deposited with the administrator for safekeeping. The manager provided evidence that a new locking system for the front door has been quoted for, and there was also evidence that new bedroom carpets, Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 19 and new conservatory flooring and blinds have been requested by the registered manager. Portable electrical appliance testing was being carried out during the visit and there is a fire risk assessment in place. Up to date records were seen for weekly bed rail inspections, weekly fire system checks, monthly wheelchair checks, hoist servicing and water temperatures. All kitchen records were up to date and risk assessments were in place. COSHH data sheets and risk assessments were available. There was evidence of quality assurance activity such as monthly accident audits, monthly inspection requirements audit, complaints audits and staff vacancy audits. The registered manager said that a survey for residents and relatives has been sent out recently and they are awaiting return of the forms. There is an on-call rota for managers and staff said that they are always able to contact a manager if they have need. The registered manager has produced a file, which guides staff to the whereabouts of all the information that may be required during an inspection of the home by the Commission. Wainfleet Care Home DS0000066378.V304667.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 X X 3 X X 3 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 3 17 X 18 3 3 X X X X 3 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 3 X X 3 Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 21 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. 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. Refer to Standard Good Practice Recommendations Wainfleet Care Home DS0000066378.V304667.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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