Inspection on 12/08/05 for Waynes The

This inspection was carried out on 12th August 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

Waynes The 03/04/07

Waynes The 22/02/06

Waynes The 25/01/05

Waynes The 24/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Waynes 7 Marton Road Bridlington East Yorkshire YO16 7AN Lead Inspector M.A. Tomlinson Unannounced 12th August 2005 09:30 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 Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Waynes Address 7 Marton Road Bridlington East Yorkshire YO16 7AL 01262 672351 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 Ann Louise Benson Mrs Ann Louise Benson Care home only 30 Category(ies) of OP Old age (30) registration, with number of places The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25.01.05 Brief Description of the Service: The Waynes provides accommodation and non-specialist personal care for a maximum of thirty (30) older people. Short-term or holiday stays are aslo provided. Nursing care is not provided. Should such care be required on a short-term basis then it will be provided by the community health care services. The home is a detached property set in large secluded grounds. It is conveniently located for all of the main community facilities including the public transport network. The service users private accommodation is located on the ground and first floor. A passenger lift provides access to both floors. There is a ramp to the main entrance and level access to the side entrance. Internally the home has been designed to take into account service users with poor mobility. The main entrance area has retained its original features and provides seating for service users and visitors. The home has several lounges of varying sizes and two dining rooms. The majority of the bedrooms are for single occupancy. Several have en suite facilities. The home has its own minibus and the registered person endeavours to provide trips out for the service users on a daily basis. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first of two statutory unannounced inspections to be undertaken by the Commission for Social Care Inspection during this inspectoral year. The inspection took six hours in total including one-hour preparation time. The registered provider delegated the responsibility for assisting with the inspection to the deputy manager in order to give her experience of the inspection process. A number of service users were spoken to in their rooms without staff being present. Others were spoken to in a group setting. Discussions were also held with several staff. A tour of the premises was carried out. A number of statutory records were examined. Feedback from the inspection was provided for the registered provider. What the service does well: What has improved since the last inspection? The registered provider and the staff had continued to build on good standards of care and to look at ways of improving the quality of life for the service users. Those requirements identified during the previous inspection had been addressed. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 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 Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 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 Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 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) 1,2,3,5 and 6 The service users had been provided with adequate information and had attained sufficient knowledge of the home and its services so as to be able to make a considered decision as to whether they wished to live in the home. EVIDENCE: The registered provider had developed a Statement of Purpose and a Service Users’ Guide. It was apparent from discussions with the service users that they had been provided with a copy of the Guide. They had also been provided with a statement or contract of their terms and conditions of residence. The operation of The Waynes was somewhat unusual insofar as the home provided short-term care for approximately five older service users on the basis of a holiday. These service users did require personal care. This diverse approach had been taken since the home was originally registered. The majority of the ‘holiday’ service users came from the West Riding of Yorkshire and many had decided that as they had enjoyed their time in the home they would stay permanently. The majority of those service users spoken during the inspection came into this category. The outcome to this was that they had The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 9 made a positive decision to be admitted into The Waynes and had a clear understanding of the services that the home provided. The service users said that The Waynes fully met their expectations and none expressed any regrets at having made the decision to live there. The home had a waiting list for admissions. All of the service users had been assessed prior to their admission into the home. This included those service users accommodated for short-term or holiday care. A copy of the assessment was with the respective service user’s care records. Three were inspected. The assessments clearly identified the primary needs, including nutritional needs, of the service users and it was evident that they were used as the basis for the development of the initial care plan. A risk assessment, including a manual handling assessment, had also been undertaken on each service user. Intermediate care was not provided by the home. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 10 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 and10 Clear and consistent care plans had been developed for the service users that provided the staff with adequate information by which they could successfully meet the service users’ needs. EVIDENCE: All of the service users, including those on short-term care, had been provided with a care plan by the home. In some cases this was in addition to a care plan developed by a service user’s placing agency. Three care plans were inspected and case tracked. The care plans were clear and unambiguous and identified the physical, social and emotional needs of the service users along with the actions to be taken by the staff to meet those needs. The service users or their representative had signed the care plan in agreement. There was recorded evidence that the care plans had been regularly reviewed and amended as necessary. The care plans were cross-referenced into other documentation such as the daily records. The care records provided evidence that the home received good support from health care professionals and that the service users’ health care needs had been met. The service users also said that they received a good service from the local medical practice. The home employed a ‘key worker’ system with nominated members of the care staff responsible for overseeing allocated service users. According to the registered The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 11 provider considerable efforts had been made to ensure the compatibility of the key worker with the service user. The names of the key workers were identified on a notice in each bedroom. Those service users spoken to were aware of their key worker. According to the staff a primary role of the key worker was to spend ‘quality time’ with the respective service user to ensure that their needs were being met. Time spent in this way was recorded in the care records. It was evident from an inspection of the records and discussions with the service users and staff, that the service users were treated with respect. It was observed that the staff spoke to the service users in a respectful but friendly manner. Whilst there was natural ‘banter’ between the staff and service users it was respectful and in good taste. It was evident that a good relationship existed between the service users and the staff and that the service users were not reticent in speaking their mind or offering their opinion. The home continued to use a monitored dosage system for the administration of the service users’ medication. The medication was appropriately secured with separate arrangements being made for controlled drugs. Nominated members of staff were responsible for the administration process and from the description of the process provided by the deputy manager it was apparent that appropriate actions had been taken to minimise the chance of error. The nominated staff had received training from the local pharmacist but it was not recorded that their competence to undertake the administration process had been assessed. Some of the service users either fully or partially selfadministered their medication. In such cases they had been provided with lockable facilities in their rooms in which to keep their medication. One of these service users stated that they kept a record of the administration of their medication and that this was available to the staff. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 12 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 The service users were provided with good standards of support that enabled them to retain a reasonable level of independence. EVIDENCE: The majority of the service users had had previous experience of the home by having had ‘holidays’ there. Consequently they were aware of the facilities and service on offer before they were admitted on a permanent basis. All of the service users spoken to were complimentary regarding the service provided and in particular the efforts of the staff to provide a homely and pleasant environment. Comments from service users included, “ It’s a friendly and relaxed place and the staff are very helpful”, and “It’s brilliant here. You couldn’t be better looked after. The staff are great”. Whilst there was not a set programme of activities, it was evident from discussions with the service users that a range of social activities were provided that endeavoured to take into account their diverse range of needs. Perhaps the appreciated activity was the daily trip out in the home’s mini-bus. All of the service users were provided with an opportunity to participate in this activity but only a limited number did so. A record was maintained in each service user’s care records of their participation in social activities. The majority of the service users presented as being motivated and stimulated. They were very communicative and had retained a sense of humour. They confirmed that boredom was not a problem although some did admit to feeling ‘down’ or depressed on occasions. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 13 Those service users spoken to had maintained good contact with friends and family and the majority had regular visitors. The more able service users, particularly those on short-term care, were able to go out unsupervised. It was observed that the service users were encouraged by the staff to do as much as possible for themselves thereby retaining some independence. One service user stated, “It’s brilliant here, you can do what you like”. It was also apparent that they were encouraged to make choices for themselves and retain control over their lives. An example of the latter point was that they, or their representative, retained financial control of the service users’ personal money. Only one service user did not have family members to advise and help them. This service user had the services of a solicitor. The service users confirmed that a representative of a local church made regular visits and communion was held either on an individual or group basis. A relative of a service user who was contacted by telephone expressed complete satisfaction with the care provided by the home. The home had a dedicated cook or housekeeper who had been working at the home for a considerable number of years. She demonstrated a good understanding of the service users’ dietary needs and of individuals’ specific nutritional needs. The menus were varied and provided a balanced diet. A genuine choice of meal was available. The service users’ choice of meal had been obtained the day before the planned meal. Records were maintained of this. The service users were aware of the planned meal. Without exception the service users spoke highly of the quality of the meals. Good liaison had been established between the housekeeper and the home’s management and care staff. Consequently the housekeeper was very aware of those service users who had a poor appetite and required monitoring. The majority of the service users had their meals in one of the two dining rooms. Some had, however, chosen to have their meals in their rooms. Hot and cold drinks were readily available to the service users and it was noted that some service users had refreshments in their rooms. All of the rooms inspected had a refrigerator in which the service users could keep cold drinks. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 14 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) None EVIDENCE: Not assessed on this occasion. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 15 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) 19,20,21,22,23,24 and 26. The standard of the environment was good thereby providing the service users with a homely and attractive place in which to live. EVIDENCE: The home was maintained, decorated and furnished to a good standard. It was very clean and totally free of any offensive odours. According to the service users, this standard of cleanliness was the norm. Only one shared room was in use and that by a husband and wife. It was the stated policy of the registered provider that rooms would not be shared unless with the expressed wish and agreement of the occupants. All of the rooms inspected were of an appropriate size. Some of the bedrooms of the permanent service users were more akin to bed-sitting rooms with one service user having two rooms one of which she used as a lounge/dining room. It was evident that the service users had been encouraged to furnish their rooms with their personal possessions. This not only personalised their rooms and gave the service users a degree of ownership over their environment but also ensured that they The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 16 retained memories of a past life. Some of the bedrooms had en suite facilities. The registered provider stated that she plans to provide the majority of bedrooms with such facilities. It was noted that the majority of the service users had a telephone fitted in their bedrooms and that others had mobile phones. One service user stated, “This enables me to keep in contact with my family”. The number of communal rooms provided the service users with a choice as to where and with whom they wished to spend their time. The service users had named one lounge area on the first floor as ‘The Crows Nest’. Several of the more able service users used this area for discussions, “in order to put the world to rights”. The home had adequate numbers of bathrooms, showers and toilets. Two of the baths had hoists to assist the less mobile service users. A mobile hoist was available. A number of service users used wheelchairs including one electric wheelchair. Some of the service users had special mattresses to minimise the occurrence of pressure sores. The environmental issues identified during the previous inspection had been, or were in the process of being, addressed. This included an extension to the call system to include all bathrooms and toilets and the fitting of radiator safety guards. The home presented as an informal and relaxed environment and did not have the ambience of a ‘traditional’ residential setting. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 17 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 Staff morale was high which resulted in an enthusiastic and capable team that worked positively with the service users to improve their whole quality of life. EVIDENCE: From an examination of the staff roster it was apparent that there had been no regression in terms of staffing since the previous inspection. According to the care staff the level of day staffing enabled them to spend time with the service users on a one-to-one basis in addition to undertaking their other care tasks. The service users confirmed that the staff answer all calls promptly and provide care with patience and friendliness. Those staff spoken to demonstrated a good understanding of their roles and of the needs of the service users. They were also aware of those elements of care, such as the promotion of independence, that go to provide the service users with a good quality of life. Three staff records were examined. They contained documentary evidence that two written references and a CRB/POVA check are obtained on all prospective staff. They also contained a record of the staff’s training. This indicated that the majority of the staff had either attained, or were in the process of attaining, a National Vocational Qualification at level 2 or 3. The deputy manager had obtained the Registered Manager’s Award and two other senior members of staff were intending to do so. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 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 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) 31,32,33,35,36,37 and 38 The registered provider had a clear vision for the home and the expected standards of care. This was reflected in the attitude and professionalism of the staff. EVIDENCE: The registered provider had extensive experience in running the home. She had attained a National Vocational Qualification (NVQ) in management at level 5 and had just completed a NVQ at level 4 in care. As previously stated the deputy manager had completed the Registered Manager’s Award. The registered provider demonstrated a democratic style of management and had encouraged the staff to be directly involved in the running of the home. Where possible staff had been delegated appropriate levels of responsibility. It was apparent that staff morale was very high with the outcome being that there had been a relatively small turnover of staff. The registered provider also demonstrated a good standard of business acumen and acknowledged that it The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 19 was important to listen to the views of the customers, in this case the service users, and develop the service in line with their needs and expectations. A quality assurance process was in place so that the home could assess the success, or otherwise, of the service. When asked to whom they would refer if they had a problem or concern, without exception the service users replied that it would be the registered provider. One service user said that if newly admitted service users were unsure or discontent she would invariably make them contact the registered provider. As previously stated in this report the service users or their representatives had been encouraged to retain responsibility for the service users financial affairs. There was recorded evidence that the staff had been regularly and formally supervised/appraised. The staff also confirmed this. Responsibility for staff supervision/appraisal had been delegated to the senior members of staff. A number of records were inspected including the fire and accident records. The staff records indicated that the staff had received training in health and safety including first aid, fire, moving and handling and food hygiene procedures. From an inspection of the premises it was evident that appropriate action had been taken by the registered provider to ensure a safe environment for the service users and the staff. Risk assessments had been undertaken and regularly reviewed. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION 3 4 3 3 3 3 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 x x x 3 4 3 x 3 3 3 3 The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 21 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 9 Good Practice Recommendations The competence of the staff responsible for adminstering the service users mediaction should be assessed and recorded. Consideration should be given to providing these staff with formal training in the safe handling of medication. The Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 4, Triune Court Monks Cross York YO32 9GZ 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 Waynes J53-J04 S19759 The Waynes V240951 110805 Stage 4.doc Version 1.40 Page 23 - 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. 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