Inspection on 19/12/05 for Wayfield Avenue Resource Centre

This inspection was carried out on 19th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wayfield Avenue Resource Centre 30/05/07

Wayfield Avenue Resource Centre 24/04/06

Wayfield Avenue Resource Centre 10/08/05

Wayfield Avenue Resource Centre 08/03/05

Wayfield Avenue Resource Centre 30/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Wayfield Avenue Resource Centre 2 Wayfield Avenue Hove East Sussex BN3 7LW Lead Inspector Paul Endersby Unannounced Inspection 19th December 2005 09:15 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 Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wayfield Avenue Resource Centre Address 2 Wayfield Avenue Hove East Sussex BN3 7LW 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) 01273 295880 01273 295900 sarahlines@southdowns.nhs.uk Brighton & Hove City Council Sarah Louise Lines Care Home 24 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (24) of places Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twenty-four (24) Service users must be aged sixty-five (65) years or over on admission Only older people with mental health needs are to be accommodated. One named service user with dementia may be accommodated. Date of last inspection 10th August 2005 Brief Description of the Service: 2 Wayfield Avenue is registered to provide accommodation and personal care older people with functional mental health needs. The home provides mostly long term placements, with two placements allocated to respite care. The registered provider is Brighton and Hove City Council. Wayfield Avenue is located in Hove with access to local transport and amenities. The premises are set out over three floors. There is a passenger lift. All bedrooms are single and have en-suite facilities. There is a good range of communal space. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning and early afternoon. The Inspector met with the registered manager and other staff members plus some of the residents. He made a tour of the building and reviewed a range of records and other documentation including some care plans. The inspection lasted nearly six hours. What the service does well: What has improved since the last inspection? 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. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 6 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 Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 7 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): 1,2 & 5 The written information available to prospective and current residents needs to be updated. Opportunities are provided for residents and their families to visit and assess the quality and suitability of the home. EVIDENCE: A statement of purpose and service user’s guide have been prepared which provides a range of helpful information for both prospective and current residents. However both documents need to be updated to reflect the current situation in relation to the services provided at the home. A comprehensive statement of terms and conditions has been produced relating to admission of people to the home. These are given to prospective residents prior to admission and are signed by them or their relatives/representatives. Prospective residents are encouraged to visit the home prior to admission. Where this is not possible then family member will often do so on their behalf. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 8 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, 9, & 10 The care planning arrangements are not being used to their full potential for the benefit of residents and need to be reviewed. The systems for administering and recording medication provide protection for residents. Residents feel that they are treated with dignity and respect. EVIDENCE: A sample group of care plans were reviewed. The last inspection identified the need to ensure that all sections of the care plan were completed. Whilst some progress has been made in this regard, it was evident that the process is still incomplete. As a result there is only limited information available to staff in regard to the assessed needs of residents and the action required to meet those needs. It is also apparent that much of the information is communicated verbally to staff at handover meetings. As a result not all staff receive the same information which can lead to a lack of consistency of response by the staff team. There are two files on each resident, a main file and a working file. In some cases some of the key information is retained in the main file and therefore not actively used by staff. In some cases this includes the social work assessment. Further, the information kept on the files varies from one resident Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 9 to another. The Inspector stressed the need to ensure that care plans set out in detail the action which needs to be taken to ensure that all aspects of the health, personal and social care needs of residents are met. Action has been taken to ensure that all the monthly reviews are completed and recorded accordingly. Residents are invited to sign their care plans and reviews, although some decline. Risk assessments have been completed. Daily recording is made for each resident, and these entries were found to be up to date and well written. There are comprehensive written policies in regard to the administration of medication for the guidance and instruction of staff. All staff have received training in medication procedures and no member of staff administers medication until they have received this training. The manager carries out an audit on medication procedures every two months. In addition the medication procedures are checked by the organisation’s care standards officer on a monthly basis. However the last recorded visit by the home’s Pharmacist was in November 2004. The recommended frequency is quarterly. All residents confirmed that they are treated with dignity and that their privacy is respected. This is referred to in the statement of purpose and Service Users Charter, and is included as part of the induction programme for new staff members. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 10 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): 14 & 15 Opportunities are provided for residents to enable them to make choices on a daily basis. A varied and wholesome menu, with choices, is provided for residents. EVIDENCE: From observation on the day of the inspection and in care plans and other documentation, it is evident that staff enable and encourage residents to remain as independent as possible within a risk management framework. Residents are able to lock their bedroom doors if they wish to. There is full access to advocacy services. Residents are able to influence the overall running of the home through their regular communication with staff on a daily basis and also through the monthly residents meeting which is chaired by a representative from MIND. Residents seen by the Inspector stated that in all cases the food provided by the home is of a high standard and this was evident on the day of the inspection. The daily menu was on display and residents confirmed that alternatives are available. Fresh fruit and vegetables are provided. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 11 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): 17 & 18 Appropriate action is taken to ensure that residents legal rights are protected. Training for all staff in regard to Adult Abuse and Adult Protection needs to be provided at the earliest opportunity. EVIDENCE: There is good evidence that the staff team promote and support residents rights. Residents have access to the postal voting system should this be required. There is evidence that where residents do not have a relative or representative acting on their behalf, the staff enable them to have access to advocacy services and also specialist interpreters if required. Adult protection procedures have been prepared for the guidance and instruction of staff. In addition a copy of local guidelines for dealing with any allegations is available. Staff confirmed that they were aware of these documents. However as identified at the last inspection, there has been no recent training or refresher training for staff. It was stated that application has been made for the relevant training but as yet places have not been provided. As also identified at the last inspection training sessions on managing challenging behaviour for all staff has been given by the Registered Mental Nurse based in the home. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 12 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, 21, 22, 23 & 26 The overall standard of the environment within the home is good providing residents with an attractive and homely place to live. The communal facilities together with resident’s bedrooms are comfortable and attractive. Specialist equipment is provided when required. A high standard of cleanliness and hygiene is evident. EVIDENCE: Wayfield Avenue is a large detached building in its own grounds. There is good access to local transport and amenities. The home is on three floors, all served by a passenger lift. There is level access into all areas of the home. The garden area is accessible to residents. It is large and well kept. The whole building is well maintained and equipped. There is a large communal area on the ground floor and further small lounge/dining areas with attached kitchenettes on the upper floors. These areas are well furnished and equipped. Furniture and lighting are domestic in nature. Action has been taken to rectify most of the maintenance items identified at the last inspection. However others remain Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 13 outstanding, including improvements to the decorative state of the second floor communal area. Windows in the home are to be replaced early in the New Year. Within the building there are sufficient toilets and assisted bathing facilities. All bedrooms are spacious and have en-suite toilet and shower facilities. Most of the residents are fully mobile with just one of the present group requiring the use of a wheelchair. However the building is well equipped with mobility aids, including assisted baths and toilets should these be required. In this event then residents are provided with environmental adaptations and disability equipment that meet their individually assessed needs. The overall design of the building allows for sufficient space for the movement of residents safely. The building was assessed some two years ago by an Occupational Therapist and a full report was produced at that time. More recently there as been an assessment of the building to ensure compliance with the Disability Discrimination Act and the required work will commence shortly. On the day of the inspection the home was clean and free from offensive odours throughout. There are infection control policies and staff receive training in this aspect of care practice. Hand washing facilities have been provided in the kitchen/diner areas. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 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 & 30 The training of staff contributes to the overall safety of residents. However not all staff have yet undertaken the core training. EVIDENCE: It is evident that the management and staff of the home take a proactive approach to the National Vocational Award system. At the time of the inspection the staff team included 26 care staff, seven of whom have successfully completed NVQ level 2 in care, and two have achieved level 3. Currently four staff members are studying to achieve level 2, and one is in training for level 3. Assuming all those in training are successful then the home will achieve just over 50 trained staff, which is the recommended National Minimum Standard. A comprehensive staff training programme is provided for staff. This encompasses core training, plus topics related specifically to meeting the needs of older people with mental health problems. However not all staff have yet had the opportunity of undertaking the full programme of core training. This includes first aid, food hygiene and adult protection. A comprehensive induction training programme is provided for all new staff which includes the Skills for Care training programme. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 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): 31, 32, 33, 35 & 38 The home is managed by a suitably qualified and experienced manager who provides clear leadership. Appropriate arrangements have been made for providing a safe environment for residents. EVIDENCE: The home’s manager has held the post since September 2004. Since the last inspection her formal registration by the Commission for Social Care Inspection has been completed. The manager holds the required qualifications and has extensive relevant experience. The manager confirmed that she undertakes periodic training to update her knowledge and skills. It was evident from the interviews with staff and residents plus the administrative systems that the manager provides good leadership and is perceived as someone who is approachable and listens and responds to ideas and suggestions. Notwithstanding this it is disappointing that there are a Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 16 number of matters requiring action, some of which were identified at the last inspection. It is acknowledged that only four months have elapsed since that inspection. Regular meetings for all staff are held on a six weekly basis. In addition there is a meeting every four weeks for care staff only. Feedback questionnaires are given to residents who receive respite care. It was reported that action is in hand to provide a similar document for permanent residents. This work is being undertaken in conjunction with MIND. The outcome of these questionnaires will be included in the Service Users Guide. Currently there are comment cards available for residents or visitors to complete. However it was acknowledged that the residents receive few visitors. A visit by a representative of the service providers is undertaken on a monthly basis as required by the Care Homes Regulations 2001. However reports for the last three months were not available for inspection. There are detailed policies and procedures operating in the home in relation to the management of resident’s finances. Residents are enabled to manage their own finances where possible. Records relating to the monies kept by the home for residents are maintained. There are extensive policies and procedures related to health and safety and systems to assess and manage risks. Risk assessments have been completed on safe working practice including radiators, hot water and windows. Hot water is temperature controlled and outlets checked showed that water was delivered within the safe temperature range. Records confirm that electrical systems and appliances have been checked. Fire alarms and emergency lighting checks are recorded and up to date. Service contracts are in place for the fire detection and fighting equipment. Fire drills are regularly and recorded and regular fire safety training is provided for staff. There are written fire procedures throughout the home. COSSH risk assessments have been carried out on hazardous substances. A record of accidents is maintained. Records show that staff have undertaken mandatory training, including manual handling and fire safety. Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 2 3 X 3 3 3 X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 2 3 X X 3 Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1)(c) & Schedule 1 Requirement Timescale for action 31/03/06 2 OP1 3 OP7 4 OP18 5 OP19 6 OP30 The Statement of Purpose must be reviewed to ensure compliance with the Care Homes Regulations 2001 and the revised National Minimum Standards. 5(1&2) The Service Users Guide must be reviewed to ensure compliance with the NMS and a copy made available to all service users and the Commission. 15(1) The care planning system must be reviewed to ensure that they are consistent and set out in detail the action which needs by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. 18(1)(c) Provide training in adult (1) protection for staff as needed. (Outstanding from the last inspection) 23(2)(m) Action must be taken to improve &(4)(c)(1) the decorative state of the upper floor communal area. (Outstanding from the last inspection) 18(1)(c) Staff must undertake all training (i) appropriate to the work they perform 31/03/06 31/03/06 31/03/06 31/03/06 19/12/05 Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 19 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 Wayfield Avenue Resource Centre DS0000031667.V254703.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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