Inspection on 27/01/06 for Weald Hall

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Weald Hall 04/02/08

Weald Hall 27/02/07

Weald Hall 21/09/05

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 Inspection 27th January 2006 10:00 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 Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Weald Hall Address Mayfield Lane Wadhurst East Sussex TN5 6HX 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) 01892 782011 Crossways Trust Limited Louise Coppard Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty five (25). That the care home provides personal care to older people aged sixty five (65) years or over on admission. 21st September 2005 Date of last inspection 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 DS0000064881.V280610.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place on the 27th January 2006 from 10 am to 4pm. Prior to the Inspection the registered manager had completed a pre Inspection Questionnaire that provided the Inspector with statistical information relating to the home. During the Inspection discussions were held with the registered manager and deputy manager regarding the day-to-day running of the home, with service users regarding their experience of living in the home and with visiting relatives regarding their impressions of the services provided by the home. As part of the Inspection the Inspector joined service users in the dining room for midday meal. A range of documents and records were examined. What the service does well: What has improved since the last inspection? The information contained in the care plans have improved in relation to the support service users require from staff in their daily living. A key worker system has been introduced. Quotes have been obtained for all windows to be fitted with restrictors and all radiators guarded. The work should be completed later this year. In the mean time risk assessments have been undertaken and risks minimised. The potting up of medication has stopped and the procedure for the administration of medication has improved. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 6 Management, in consultation with service users, have reviewed arrangements for mealtimes. However, further consultaion is required. Consultation has taken place with service users regarding the provision of activities in the home. Service users stated they were happy with the current arrangements. 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. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5. Prospective service users needs are adequately assessed and know the home can meet their needs. All service users have a written contract/statement of their terms and conditions. EVIDENCE: The registered manager prior to admission assesses prospective service users needs. Two visiting relatives confirmed that following an initial telephone enquiry that they had visited the home for a look round. Arrangements were then made for their relative to come to the home for lunch and the registered manager visited the prospective service user at home to undertake the pre admission needs assessment. They also confirmed that the contract stated that the first month’s stay was on a trial basis and the manager had explained that this to them. Two pre admission assessments and a copy of the contract/terms and conditions were examined and found to be adequate. However, it is recommended that the home confirms in writing that they are able to meet the service users needs prior to them being admitted to the home. It is also recommended that the manager keeps a record of the assessment process Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 9 detailing dates of visits to the home by prospective service users, dates pre admission assessments are completed, where and by whom and that any other information, in respect of prospective service users needs should be dated when it is received. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10. Not all care plans are adequate. Service users health care needs are met and they are treated with respect. EVIDENCE: Four care plans were examined and not all adequately detailed the guidance required for staff to follow when supporting service users in their daily living. It is required that care plans cover all the areas specified in Standard 3 and that they are reviewed on a monthly basis. A visiting health care professional spoke highly of the care provided by the staff team and commented that they often ring for advice in relation to service users specific health care needs. She also stated that referrals are made for service users to be assessed on a regular basis, equipment that will promote independence is provided and any instructions she leaves for staff are followed. Requirements made in relation to service users medication being documented on their care plans have not been met and further requirements are made. The Inspector had discussions with 6 service users, 2 visiting relatives and 1 visiting health care professional. Everyone stated that they are referred to by Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 11 their preferred term of address, receive their own mail, can have a phone installed in their room and that staff always knock on their doors before entering. The health care professional confirmed that service users receive treatment in their own rooms and relatives stated that they felt their relative was treated respectfully and their dignity maintained by the staff team. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 the following standard(s): 12,14,15. Service users lifestyles in the home match their expectations. The food provided is wholesome and appealing. Generally service users are supported to exercise choice and control over their lives however, in relation to arrangements for the provision of the midday meal choice is not promoted. EVIDENCE: Service users have the opportunity to participate in meaningful and enjoyable group activities in the home. Service users stated that they were happy with the frequency and type of activities provided by the home. The home now employs an activity organiser who consults with service users on a regular basis as to their preferences. Activities include, quizzes, sing-along, theme days, trips out, bible study group, arts and craft, visiting musician etc. Information is displayed on a notice board and all service users receive a programme of activities and events on a monthly basis. The Inspector joined service users for their midday meal. There was a menu on the table and the table was laid formally. The food was hot, homemade, well presented and wholesome. Records show that a varied menu is provided. Records also detail what and where service users have eaten so that appetite can be monitored. Likes and dislikes are recorded on the care plan and the cook also has a copy. Currently a choice is not offered for the midday meal but the home has plans to introduce this in the near future. A dietician is visiting Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 13 the home to give advice regarding menu and diet for specific service users and two members of staff have undergone training in relation to the provision of food in the care setting. Through discussions with service users and staff it is apparent that there remains a level of dissatisfaction in relation to the arrangements for mealtimes in respect of the length of time between courses. Six service users stated to the Inspector they did not like the wait between courses. Two members of staff also confirmed that service users had complained to them about this issue. It is required that at meal times all service users must have the choice of whether or not they wish to wait for others to finish one course before the next is served to them. Further consultation must be undertaken in respect of this matter and alternative arrangements be sought so that those service users who do not wish to wait for all service users to finish one course before another is served, do not have to. It is recommended that any consultation undertaken is done so on a one to one basis and not in a group setting. The results of this consultation must be made available for Inspection. Service users are able to choose when they go to bed, when they get up, where and at what time they wish to eat, whether or not to participate in group activities etc. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 the following standard(s): 16. The homes’ complaints policies and procedures are adequate. EVIDENCE: The home’s complaints policies and procedures were examined and found to be adequate. Serviced users and 2 visiting relatives stated that they would go to the manager if they were dissatisfied with any thing and that they felt she was open and approachable. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 the following standard(s): 19,25,26. Service users live in a safe, clean and hygienic environment that is well maintained. Not all risk assessments in relation to service user safety contain sufficient detail. EVIDENCE: On the day of the Inspection the home was found to be clean and hygienic. Carpets were being professionally cleaned and the manager explained that this is done on a regular basis. The home employs domestic staff who undertake the majority of the cleaning tasks in the home. Service users stated that their rooms are cleaned on a regular basis. The home is well maintained and the manger explained that plans for a 2 year, 5 year and 10 year programme for redecoration is under discussion. The home and grounds are accessible to all service users, subject to a risk assessment, and there is level access throughout. Recommendations made by the fire service are being complied with and the Environmental Health department are due to visit the home later this year. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 16 Many of the radiators in service users bedrooms are unguarded and many of the windows do not have restrictors fitted. The manager explained that she had completed risk assessments and that there are plans for guards and restrictors to be fitted later in the year. Risk assessments were examined and further detail is required to specify how identified risks are being minimised. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 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): These standards were not Inspected. EVIDENCE: Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,38. This home is well managed by a competent and experienced manager and service users benefit from her management approach. Service users financial interests are protected. Further steps are required to be taken to ensure service users safety is promoted at all times. EVIDENCE: The registered manager of the home has all the relevant qualifications and experience required to run this home and continues to update her knowledge by attending courses relevant to her position. Staff, service users, a healthcare professional and 2 visiting relatives all spoke highly of her. It is evident that there is an open door policy and that people find her approachable. There appears to be a good working relationship between the manager and the organisation she works for and there are clear lines of accountability. This working relationship and the fact that the manager and staff team are enthusiastic and open to new ways of working appears to be having a positive and beneficial affect on the service users resident in the home. Letters that Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 19 had been received by the home from relatives confirmed that Weald Hall is “homely” and that there have bee improvements recently. Service users finances are not handled by the home. Records were examined in relation to health and safety and found to be in order. Discussions took place with the manager in relation to the risk assessment process. It has already been identified within the report that some risk assessments are inadequate. The manager explained that the responsibility for undertaking risk assessments in relation to the home and grounds will be undertaken by a professional organisation in the near future, including for when the new kitchen is built. However, there are some areas for which the manager will still be responsible, in particular for ensuring the health, safety and welfare of service users. In relation to this the home is required to implement a new policy and procedure for the reassessment of service users following an accident or incident in particular following a fall. It was evident from the records that although the manager and staff immediately reassess the service user and do health checks etc there isn’t a policy or procedure top follow or any where specific for them to record their actions. It is recommended that advice be sought on the use of a falls assessment tool to assist in this procedure. Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X 2 3 STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X x 2 Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15(1,2abc d)13(4bc) 13(2) 13(2) Requirement Care plans must contain all information as specified in standard 3 and be reviewed on a monthly basis. To have risk assessments for any self-administration in the home. For any self administration. To have individual self administration detailed procedures as part of the care plan. At meal times all service users must have the choice of whether or not they wish to wait for others to finish one course before the next is served to them. Further consultation must take place, this must be documented and available for Inspection. Risk assessments in relation to unguarded radiators and windows without restrictors must specify how identified risks are being minimised. A policy and procedure must be introduced in respect of the actions staff should take following a service user being DS0000064881.V280610.R01.S.doc Timescale for action 30/03/06 2. 3. OP9 OP9 14/03/06 14/03/06 4. OP14 12(2,3) 16(2i,4) 30/03/06 5. OP25OP38 13(4ac)(6 ) 14/03/06 6. OP38 12(1) 13(1 to 8) 30/04/06 Weald Hall Version 5.1 Page 22 involved in an accident or incident in particular in relation to falls and the reassessment required. 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 OP14 Good Practice Recommendations To ensure written policies around medicine management are localised. It is recommended that any consultation undertaken is done so on a one to one basis and not in a group setting. The results of this consultation must be made available for Inspection. It is recommended that the home investigate using a falls assessment tool. 3. OP38 Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Weald Hall DS0000064881.V280610.R01.S.doc Version 5.1 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. 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