Inspection on 29/11/07 for Wayside

This inspection was carried out on 29th November 2007.

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

Wayside 18/11/08

Wayside 13/07/06

Wayside 16/12/05

Wayside 25/04/05

Wayside 03/12/04

Wayside 20/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Wayside High Street Rusper Horsham West Sussex RH12 4PX Lead Inspector Sheila gawley Key Unannounced Inspection 29th October 2007 09:00 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 Wayside DS0000014823.V347354.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. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wayside Address High Street Rusper Horsham West Sussex RH12 4PX 01293 871365 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) Hope Keith Villagers Trust Ruth M Elhamad Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 Brief Description of the Service: Wayside is registered to provide care and accommodation for thirteen older people over the age of sixty-five. The premises provide each resident with a single room on the ground or first floor both of which are serviced by a passenger lift. Most rooms have en-suite toilet and wash-hand basins and one room is used to accommodate people who wish to have a short break at the home. It is situated in the village of Rusper, West Sussex close to a local shop and a church. There is no bus service but a Good Neighbours transport scheme helps people get to appointments such as hospital visits. Whilst the home fronts onto the village high street there are large grounds to the rear of the property, which are accessible and enjoyed by all residents. The fees charged are 3480-£560 Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit as part of the inspection process took place on the morning and afternoon of 29 11 07. The registered manager facilitated the inspection. The commission was in receipt of an Annual Quality Assurance Assessment (AQAA) and any documents required on the day were made available. Nine residents were accommodated on the day of inspection, with two others being in Hospital. Two residents were case tracked, their care plans and Medicine administration charts were inspected and they were also spoken to. They expressed satisfaction with most aspects of the home saying that staff were very caring but that the choice of food could be improved. All residents spoken to throughout the day stated great satisfaction in the care they receive, that they are always treated in a respectful manner and that they enjoyed the activities provided. One relative was spoken to on the day and he expressed great satisfaction with the home. Staff were very approachable and any concerns were quickly dealt with. Another Visitor spoken to on the day stated that he had been visiting for many years and stated that the home was very good. Staff were observed offering care in a respectful and encouraging manner. The atmosphere in the home was very relaxed and sociable. This report is compiled using information as described above and also information held on file at the Commission. The majority of the standards were met today mostly judged as good but there were shortfalls in the completion of risk assessments, choice of food offered, the containment of fire and passenger lift safety. The home also needs to report to The Commission all accidents and incidents. These issues were discussed with the Registered Manager. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Wayside DS0000014823.V347354.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 Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use this service experience good outcomes because needs are assessed prior to admission This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have a preadmission assessment. These were seen in the care plans inspected. The assessment covers all aspects of care. A relative spoken to confirmed this and expressed satisfaction with all aspects of the admission process. All residents are I invited for a meal prior to admission and are then offered a months trial. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7-10 People who use this service experience good outcomes because all needs are assessed, set out in a plan and met. Medicines are handled appropriately and residents are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had a plan of care. Two residents were case tracked. The care plans inspected contained information on health, personal and social need. The care plans were drawn up following an assessment of their needs including continence assessments from a continence advisor. Risk assessments are not routinely recorded, for example to consider what steps need to be taken to prevent falls or pressure sores. The daily notes were up to date but one did not have up to date monthly review. The need to include risk assessment to make care plans more comprehensive was discussed with the manager and will be a requirement of this inspection. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 10 The residents are involved in the development and maintenance of their care plans as are their relatives/representative where appropriate. Access to specialist health support is available as required including general practitioner, chiropodists, opticians, dentists and outpatient appointments. Residents are helped with personal care as appropriate. Medicines are stored, administered, recorded and disposed of appropriately. Medicine administration charts inspected were up to date. Staff were observed offering care in a respectful and encouraging manner and residents spoken to stated that they are treated with respect. A relative spoken to also confirmed this. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 People who use this service experience adequate outcomes because although residents were satisfied with their lifestyle at the home and they maintained contact with family and friends, they and could not exercise choice and control over their choice of meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an activities programme in the home, which is displayed on the notice board. This includes in house activities and some external entertainers who provide armchair exercises and music. Residents spoken to state that they enjoyed the activities, one saying, “I especially enjoy Wednesdays”. Another on the day however, stated that she could not go down for the entertainment today as the lift was broken (see Standards 19-26). One resident stated that weather permitting she enjoyed gardening. There is monthly communion and residents are encouraged to maintain contact with friends and relatives. Two Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 12 visitors today confirmed this stating that they are always made welcome in the home. The home owns a car so that residents can be taken out. The home does not manage any resident’s money although some deposit small amounts for safekeeping. This is safely stored and accounted for. A notice board is used to keep residents informed and it provides information about advocacy services and how to contact other outside agencies. Meals are served in a very pleasant dining room. There is a three week menu in place but it is very ridged. Residents are not offered a regular choice of meals daily. Residents and staff spoken to confirmed this. All residents were served minced meat pie today with a chocolate mouse to follow. The requests made at the last residents meeting have not been incorporated into the menu, when spoken to the manager confirmed this. The cook was spoken to and she did say that residents are asked daily what they would like to eat but staff and residents spoken to stated that this does not happen. Staff appear very reluctant to make requests. There was an appropriate food store with fruit and vegetables. There was appropriate refrigeration and freezer provision. There was however uncovered and unlabeled food in the fridge and also on the counter. This situation was discussed with the manager and the importance of residents being offered daily choice and having the menu changed following requests at residents meetings was stressed. This will be a requirement of this inspection. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use this service experience good outcomes because there is a complaints procedure, and trained staff protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear and accessible complaints procedure in place which residents spoken to stated that they were aware of, although all stated that they did not have reason to complain. Two visitors spoken to also stated that she did not have reason to complain but would know how to do so. There are policies and procedures in place regarding safeguarding adults and whistle blowing. Staff spoken to were clear about the procedures to follow in safeguarding adults allegations. Training records show that staff have training in safeguarding adults policies and procedures Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22, 26 People who use this service experience adequate outcomes because although the home is generally well maintained, neat and clean problems with the lift and the practice of wedging doors open poses a risk to the safety of residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a pleasant sitting and dining room and a seating area in the hall. The home provides a well-maintained environment and provides specialist aids and equipment to meet the needs of the people who use the service. The home is pleasant, well decorated and bedrooms are personalised. Some areas have had new carpeting. There is a well-maintained accessible garden which one resident states she enjoys helping to maintain. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 15 Radiators are covered and there are temperature control valves on taps. The manager stated that the boiler system is due for a maintenance check. Wedges were seen propping doors open and the need for automatic door closure devices to be fitted was discussed with the registered manager. The need to consult with the fire authority on this is a requirement of this inspection. The passenger lift has been malfunctioning for some months, which has not been notified to the Commission via a Regulation 37 or on the Annual Quality Assurance Assessment. On reaching the ground floor the doors do not open. On August 10th two residents got trapped in there and they had to be released by the fire brigade. On the day of the inspection the doors were again not opening and residents upstairs were unable to come down for the planner entertainment or for meals. The manager stated that the lift company are attending tomorrow. One resident has had a fall and hospitalisation as a result of this. The need for speedy repair was stressed to the registered manager and also the need to put into place a risk assessment on how to manage daily life for the residents whilst protecting them from injury. During the draft report stage of this inspection process the home was contacted and the lift is expected to be repaired in three to four weeks. This is a requirement of this inspection. The home was neat and clean throughout and free from offensive odours. A laundry is situated away from food preparation areas and has satisfactory facilities. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People who use this service experience good outcomes because a suitably recruited and trained staff meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rota showed sufficient staff on duty at all times. The home is working towards having 50 of staff trained to National Vocational Qualification Level 2. Residents spoken to stated that staff always attend when they are called. They also confirmed that they feel their needs are met by competent staff and in a respectful manner. They feel the chef could be more responsive. The cleaner is currently supplied by an agency while the home recruits another. Personnel files inspected showed that the home follows a recruitment policy and all documents required were in place. Staff do not commence work without having Criminal Records Bureau Clearance and a POVA check. Induction and training records show that staff are trained to do their job. Staff meetings are in place to discuss issues and promote best practice in the home. Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 17 Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36,38 People who use this service experience adequate outcomes in this area. The home is generally well managed by a person qualified to do so. Not all of residents’ requests are acted on. There is a risk to health and safety of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has the qualifications and experience necessary to obtain registration with the Commission. She communicated a clear sense of direction for the home and is looking forward to all maintenance work being completed. She is updating policies and key documents such as the Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 19 Statement of Purpose. She is working towards the Registered Manager Award and plans to attend more training sessions and seminars. Staff and residents state that the manager is approachable. A newly appointed deputy manager has been appointed and she is developing quality assurance monitoring systems to elicit opinions on the service from residents, relatives and staff. Staff and residents meetings are in place and the AQAA was completed and sent to the Commission. Although the AQAA states that staff have had better guidance on residents’ choice, the request for menu changes from residents has not been addressed. Small amounts of money are held for residents. These are held individually, securely and are recorded and receipted. Staff supervision is in place and record of this were seen in staff files. Residents and staff are protected by the homes induction and training programme, which ensures safe working practices and the provision of health and safety policies and procedures, which are currently being updated. The health safety and welfare of residents is however compromised by the lack of risk assessment, the unsafe practice of wedging doors open and the longstanding malfunctioning lift. The need to record and report all accidents, injuries and incidents of illness and communicable disease was discussed with the Registered Manager and will be a requirement of this inspection. Wayside DS0000014823.V347354.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 2 X X 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 2 X 3 3 X 2 Wayside DS0000014823.V347354.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. 1 2 Standard OP7 OP15 Regulation 13 (40 © Requirement The registered person must ensure service user plans of care include risk assessment The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements. The registered person To consult with the fire authority on the containment of fires The registered person to ensure service users have access to all parts of the home through the provision of passenger lifts or chair lifts where they meet the assessed needs of service users and the requirements of the Environmental Health Authority and the Health and Safety Executive. The registered person to record and report all accidents, injuries and incidents of illness and communicable disease. Timescale for action 29/02/08 29/02/08 16 2 I) 3 4 OP19 OP22 234) © 13 (4) (a) 23 (2) © (n) 29/02/08 29/02/08 5 OP38 37 (1) (2) 29/02/08 Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 22 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 Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wayside DS0000014823.V347354.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!