Inspection on 21/09/05 for Weald Hall

This inspection was carried out on 21st September 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

Weald Hall 04/02/08

Weald Hall 27/02/07

Weald Hall 27/01/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Weald Hall Mayfield Lane Wadhurst East Sussex TN5 6HX Lead Inspector Elaine Green Unannounced 21 September 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Weald Hall Address Mayfield Lane Wadhurst East Sussex TN5 6HX 01892 782011 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) Crossways Trust Limited Louise Coppard Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (OP), 25 of places Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty five (25) 2. That the care home provides personal care to older people aged sixty five (65) years or over on admission Date of last inspection New Home Brief Description of the Service: Weald Hall is a large detached house in the Snape valley, a short distance from the market town of Wadhurst, where there are shops, banks, library and post office. It provides care and support for up to 25 older people The home is approximately one mile from Wadhurst railway station. There are rail and bus links to Tunbridge Wells. The ethos of Weald Hall is to provide a comfortable and caring environment that promotes independence. Service users are encouraged to manage their own financial and personal affairs.The home has a high standard of decoration and there are spacious grounds. Crossways Trust became the registered owners on 31st May 2005. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place between 11 am and 4pm on 21st September 2005. As part of the Inspection discussions took place with the registered manager re immediate requirements made at a visit earlier in the year and the day-to-day running of the home. The Inspector spent time with service users and joined them for lunch. A range of records and documentation were examined including a selection of the homes’ policies and procedures, four service users’ care plans, two recruitment files, medication files, records relating food including menus, daily records, health and safety records, risk assessments, records of service users’ activities, staff training records and key worker responsibilities. What the service does well: What has improved since the last inspection? What they could do better: The information contained in the care plans is minimal and does not adequately specify all guidance required to support service users in their daily living. The managers proposed new system for care planning, which will require the assessment of service users’ needs in areas not covered by the current system, must be implemented by 30th January 2006. All windows should be fitted with restrictors and all radiators guarded. Where service users refuse to have these fitted in their own rooms and are aware of Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 6 potential risks involved a record must be made of this and should be reviewed regularly. Rooms should be fitted with the restrictors and guards as a matter of course as they become vacant. The potting up of medication is not considered to be good practice and it is recommended that this procedure stops. Management, in consultation with service users, must review the current arrangements for mealtimes. Service users must be offered a choice of food at every mealtime. The layout of furniture and equipment in the dining room and the adequacy of supervision at mealtime must be reviewed and reassessed in relation to service users health and safety. Consultation must take place with service users regarding the provision of activities in the home and the arrangements for them to access the community. 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. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 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 Weald Hall H59-H10 S64881 Weald Hall V246660 210905 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) 3,5. Prospective service users are provided with the information required to make an informed choice about whether to reside in the home. EVIDENCE: The manager stated that she undertakes pre admission assessments in service users’ own homes or in hospital. The assessments cover all aspects of service users care needs. The current pre admission assessment format was seen and is adequate but the manager is proposing to introduce a new system in October, this will be inspected fully at the next Inspection. The service users’ guide specifies that service users can visit the home to have a look round and that the first months stay is on a trial basis. The manager stated that, during the first month, further assessments are carried out and a care plan is drawn up in consultation with the service user. Documentary evidence was seen on the day of the Inspection to this affect. The care planning system used by the home is due to change in October and this too will be inspected fully at the next Inspection. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9. Care Plans are inadequate. Medication policy and procedures are, in the main good, though morning administration procedures need to be reviewed particularly in regard to the practice of secondary administration. Service users’ health care needs are met and staff are well informed. EVIDENCE: Four care plans were examined. The information contained in the care plans is minimal and does not adequately specify all guidance required to support service users in their daily living. However the manager proposes to implement a new system for care planning which will require the assessment of service users’ needs in areas not covered by the current system. A requirement will be made for this to take place within a reasonable timeframe. Existing care plans are reviewed on a regular basis. A key worker system has recently been introduced along with a key worker weekly schedule, which was examined. This schedule acts as a prompt for key workers to check that their key clients needs are being met and care plans are up to date. Service users’ daily records and medication records were examined and found to be accurate, informative and complete. Visits by health care professionals Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 10 are recorded, G.P and District Nurses notes are stored on the premises and care staff have access to them. Information is available to staff re all medication taken by service users including side affects that may be experienced. Staff receive training from an outside agency re the safe administration of medication. There is a comprehensive audit trail to account for all medication and examples of completed forms were seen at the Inspection. The manager explained that two members of staff transfer all the morning medication into lidded pots with service users’ names on. The manager then administers it to the service users. The practice of secondary dispensing is not considered to be good practice and it is recommended that medication is administered from its’ original packaging. A referral has been made to the CSCI pharmacist to advise the home on their medication administration procedures. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. Opportunities for service users to participate in leisure social activities are limited. Individual choice is not promoted at mealtimes. EVIDENCE: An Extend (exercise) session is held weekly and events including VE Day & St Georges Day celebrations and a day trip out have taken place. The manager explained she arranges transport for service users to access the local shops or pubs and staff support service users to walk in the grounds. A ‘Clothes Show’ is held on a regular basis and service users can buy clothes. Communion is held in the home monthly. A library service visits and residents meetings are held weekly and are informal. The manager explained that the choice of activities organised by the home are limited. A new post of activity coordinator has been created but is currently vacant. Daily records indicate that many service users spend time in their rooms watching television or reading. A requirement will be made that service users be asked about their preferences regarding daily activities and their satisfaction with current arrangements. Menus and records relating to food likes and dislikes were examined. The menu is on a 28-day cycle. No choice of meals is currently being offered. The cook has a record of all the service users likes and dislikes. It is a requirement that service users are given the opportunity to have a choice of food at each meal. This choice must not just be an alternative to foods they do not like but a real choice of meals of equal quality that they enjoy. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 12 The Inspector ate lunch with the service users. The dining room is formal and service users do not have a choice of where they would like to sit on a day-today basis, this should be reviewed. Meals were served ready plated and there were long gaps between courses, consultation must take place with service users regarding any changes they may wish to make to the current arrangements. The food served was fresh, hot, homemade and well presented. The manager stated that service users’ visitors are welcomed into the home and can have a meal with their relative if they wish. Visitors can be accommodated in the dining room, library or in the service users own room. Daily records examined showed that service users are visited on a regular basis. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The homes policies and procedures relating to complaints and the protection of vulnerable adults are adequate and implemented when required. EVIDENCE: The complaints and adult protection policies and procedures were examined and found to be satisfactory. All staff receive training in issues of the protection of vulnerable adults. The manager responded appropriately and proportionately to a recent incident of suspected adult abuse. The relevant agencies i.e. the police, social services assessment team and the CSCI were informed in line with local guidance. Records examined on the day of the Inspection gave no cause for concern. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25,26 This home is clean and well maintained. Issues of service users safety need addressing. EVIDENCE: This home is generally well maintained. The manager stated that the current owners have a 5 year rolling maintenance programme. Work on replacing the kitchen is due to start later this year. The relevant authorities have been informed and consulted and this has been confirmed in writing to the CSCI. It was pleasing to note that the fire safety officer commented that the manager has a positive attitude to fire safety matters and that the general standard of fire safety in the home is good. All windows should be fitted with restrictors and all radiators guarded. The manager stated that some service users have refused to have them fitted in their own rooms. Where this is the case and service users are aware of the risks they must sign to that affect and take responsibility for taking this risk. This should be reviewed regularly. Risk assessments for significant risks to service users and staff including those for radiators and windows, were examined and found to be up to date and relevant. Where a service user has Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 15 been assessed as being at risk and when rooms become vacant, window restrictors and radiator guards must be fitted. Staff were not present in the dining room while service users ate their meal. The layout of furniture and equipment in the dining room and the adequacy of supervision at mealtime must be reviewed and reassessed in relation to service users health and safety. The home was clean and tidy on the day of the Inspection. Domestic staff are employed to undertake cleaning tasks. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 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 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) 27,28,29,30. A well-trained and competent staff team support service users in all aspects of daily living. The homes recruitment procedures are robust. EVIDENCE: Two staff recruitment, and induction files were examined. Recruitment procedures are robust, all the required checks and references had been undertaken before staff were deployed to work in the home. Staff training records were examined and found to be satisfactory. The manager has identified and implemented a comprehensive schedule of training courses for staff to attend. The majority of the courses are provided by an agency off site, though those studying towards achieving a National Vocational Qualification (NVQ) in Care Level 2 or above are assessed in the work place. Time is scheduled for staff to spend with their assessor and this is planned in advance. Out of 16 care staff, excluding the manager, 4 have achieved NVQ in Care Level 2 or above and 5 are enrolled on a course and working towards it. The manager stated that they try to keep the agency staff used to cover vacancies to a minimum and where ever possible they try to use the same individuals. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 17 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) 31,32,33,37. This home is well run by. The administration systems in place are adequate. EVIDENCE: The manager of Weald Hall was registered by the CSCI in July 2005. She is experienced in the care of older people. Though only in post for a relatively short space of time, changes are already been implemented and a comprehensive training programme has been introduced. The new owners and manager appear to have a good working relationship. The manager commented that she feels supported by the organisation and that funds have been made available to address shortfalls that have been identified e.g. staff training and the need for the kitchen to be upgraded. Through discussions with the manager it is evident that there are more changes to be introduced to the home that will include working in consultation with service users to improve the service provided. Progress made in the Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 18 implementation of the proposed changes will be monitored by the CSCI at subsequent Inspections. All records examined on the day of the Inspection were found to be legible, accurate and complete. Copies of all signatures and initials are kept for those staff that administer medication. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 19 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 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 Standard No 16 17 18 Score x x 3 3 3 3 x x x 3 x Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 20 N/A 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 OP7 Regulation 15(1) (2,b,c), Requirement Timescale for action 30.01.06 2. OP12 OP15 14(1,a) 15(1) 16(2,h,m, n) 3. OP15 16(2(i)) 4. OP25 13(4,a,c) That service users care plans specify their assessed needs and provide the guidance required by staff to deliver care and support appropriately including daily living, participating in acivities and accessing the community. Care plans must be written in consultaion with and signed by service users or their representatives. 30.01.06 That consultation takes place with service users regarding the provision of activities in the home and the arrangements for them to access the community. Also in relation to mealtimes including, the formality of the current arrangements, the option of where to sit in the dining room, the legnth of time between courses and the way in which food is served. Service users must be offered a 30.03.06 choice of meals at each meal time. This choice must not just be an alternative to foods they do not like but a real choice of meals of equal quality that they enjoy. The health and safety of service 30.10.05 Version 1.40 Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Page 21 users in respect of the layout of furniture and equipment and the level of supervision in the dining room at mealtimes must be reviewed and reassessed. Service users who refuse to have risks minimised by adaptations must sign to state they are aware of the risks and that they responsibility for taking this risk. Where there is a risk, radiator gaurds and window restrictors must be fitted. 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. 2. Refer to Standard OP9 Good Practice Recommendations The potting up of medication is not considered to be good practice and it is recommended that this stops. Weald Hall H59-H10 S64881 Weald Hall V246660 210905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex 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. Extracts may not be used or reproduced without the express permission of CSCI Weald Hall H59-H10 S64881 Weald Hall V246660 210905 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. 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