Inspection on 08/09/08 for Weald Hall Residential Home

This inspection was carried out on 8th September 2008.

CSCI found this care home to be providing an Good service.

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 Residential Home 30/11/07

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOMES FOR OLDER PEOPLE Weald Hall Residential Home Weald Hall Lane Thornwood Epping Essex CM16 6ND Lead Inspector Diane Roberts Unannounced Inspection 8th September 2008 09:30 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 Residential Home DS0000070200.V371272.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. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Weald Hall Residential Home Address Weald Hall Lane Thornwood Epping Essex CM16 6ND 01992 572427 01708 478151 michael502@btinternet.com 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) JK Healthcare Limited Mr Michael James Stevens Care Home 39 Category(ies) of Dementia - over 65 years of age (39) registration, with number of places Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2007 Brief Description of the Service: Weald Hall is a care home registered to provide accommodation and care to thirty-nine people over the age of 65 years who have dementia related care needs. The service is not registered to provide nursing care. The home is situated in a rural location on the outskirts of the small village of Thornwood Common, near Epping in Essex. It is a fairly isolated location and is not within walking distance from the village or main road; there is no public transport. The home is set in large well-maintained grounds, surrounded by farmland with views across fields and the private airfield, which runs alongside the grounds. The gardens and patio areas are suitable and accessible to those in wheelchairs or with other mobility problems, garden furniture is provided. The older style building, renovated and decorated to a high standard, provides accommodation on two floors. Personal accommodation consists of 39 rooms for single occupancy with en suite toilet and washbasin facilities. A passenger lift provides access to the upper floor. Some communal corridors are not wide enough for the larger wheelchair. The fees charged by the service range from £550.00 to £750.00 per week depending on needs assessment and room size. There are additional charges for hairdressing, chiropody and newspapers. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The unannounced site visit was undertaken over a seven-hour period by one inspector as part of the routine key inspection of Weald Hall. Time was spent talking with the residents, relatives, staff and visiting District Nurses during the day. Due to cognitive impairment and disorientation to time and place discussion with the majority of residents with regard to care delivery was difficult. A tour of the premises was undertaken and records and policies were sampled. The manager was available throughout the day and assisted us with the inspection. The manager submitted an Annual Quality Assurance Assessment prior to the site visit. This details their assessment of what they do well, what could be done better and what needs improving. This information was considered as part of the inspection process and is reflected as part of the report. Prior to the site visit, the manager was sent a variety of surveys to distribute to relatives and healthcare professionals. Responses were received from one relative and their comments and responses are reflected throughout the report. Comments and evidence was also used from the manager’s internal quality review as this had been completed at a similar time to the Commission’s questionnaires being sent out and may account for the limited response from relatives. On day of the inspection relatives, district nurses and staff were spoken to and it was also possible to interact with residents. The outcomes of the site visit were discussed with the manager throughout the day and during feedback at the end of the inspection, where opportunity was given for clarification where necessary. What the service does well: The home provides residents with a well trained and dedicated staff team who obviously care for the residents and their well being. Relatives comments included ‘my relative has settled in and become physically so much healthier’ and ‘ my relative’s well being is plain for all to see’. Residents are also provided with a generally good activities programme and meals service. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 6 The staff are well trained and recruited properly to ensure residents safety as far as possible. The management of the home is sound and the home is run with in the best interests of residents. Concerns are dealt with promptly and objectively. 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. Weald Hall Residential Home DS0000070200.V371272.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 Weald Hall Residential Home DS0000070200.V371272.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): 1 and 3. This home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they will be properly assessed prior to admission to ensure that their needs will be met and that they will have enough information regarding the home. EVIDENCE: The manager has both a statement of purpose and service users guide in place. These are available in the main reception area, along with the last inspection report. Whilst both documents contain the required relevant information, the format of the service user’s guide is not user friendly for the resident group and should be reviewed. This was discussed with the manager. A colour brochure is also available which contains information on the home. The manager has a pre-admission assessment form in place, which he uses to assess all potential residents, to ensure that the home and staff team can meet their needs. As stated in the managers AQAA, this document has been Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 9 updated since our last visit to the home. Two recent assessments were reviewed. These were seen to have been completed fully and where appropriate, were supported by information from a social services assessment. Whilst the assessments contained a good level of information, some of which was person centred, this aspect of the assessment could be developed further in order to identify residents’ abilities and strengths rather than being fully needs led. Subsequent social work reviews following admission, evidenced that residents had settled in well and that placements at the home were appropriate. The manager has recently developed a feedback questionnaire on people’s experiences on admission to the home. It was possible to review three completed questionnaires. Overall the comments, primarily from relatives, were very positive, with people feeling that they had enough information on which to base decisions, they evidenced that staff at the home supported them and made them feel welcome, they knew how to raise concerns and that they understood the terms and conditions of the home. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their individual care needs met respectfully by the team at the home and their health is promoted. EVIDENCE: Since the last inspection, the manager has been introducing a new care planning system. Some care plans tracked are on the new system whilst others are still using old documentation. This gives a variable picture of the current state of care planning at the home. However, from discussion with relatives and their comments, discussion with the district nurses and from an overall review of the documentation, it is felt that outcomes for residents at the home are generally good. Three care plans were reviewed and other care planning documentation was also taken into account. Care plans on the new format were seen to be up to date and reflected residents needs but did not contain all the person centred and detailed, individualised information that the old system contained. This was discussed with the manager and the deputy, who said that this was still to be added and it was a priority for them. Old care plans showed that there was Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 11 a good appreciation of the diversity of the residents and their individual needs and choices. Older care plans were not always up to date and on discussion with staff, who had provided care for residents that morning, it was clear that they did not reflect all of their current needs. Reviews were evident and these contained relevant and meaningful information but some care needs had still not been addressed. On discussion, the staff knew the residents’ needs well and spoke about the residents in an individual and caring way. The manager said that he still had approximately 9 care plans to update. As part of the new system the manager has introduced new care plan front sheet, which are very person led and give a brief outline of the individual with some past and some present social information, which is useful. Social, person centred, care plans are being developed with input from the activities co-ordinators, who confirmed that they had been undertaking family and social history work with residents. Staff record daily notes on the care provided. These were seen to be informative and individual. Staff need to be careful that valuable information recorded daily, is transferred into the actual care plan and not ‘lost’ in the daily notes. The manager in his AQAA states that ‘we should regularly monitor that our staff are keeping to the care plans and that assessments are done at regular intervals’. The manager has developed a monitoring/observational tool for auditing the wellbeing or ill-being of residents with dementia and records show that he has completed approximately 8 observational audits. He is planning to link this into the care plan for the individual. Residents were observed to be at ease in the home and interacted well with the staff on duty and us, during the inspection. The most recent relative feedback questionnaires from the home included such comments about the care as ‘ x is a changed person since they have been at the home, x is much happier and x’s attitude and general wellbeing are plain for all to see’, ‘I am generally pleased with the care my relative has received in the year they have been at the home’, my relative ‘has settled in and become physically so much healthier’. Overall records showed that relatives were generally happy with the care provided at the home and records also showed that any concerns or queries raised, had been followed up. Relatives spoken to on the day of the inspection were positive regarding the care provided for their family members and comments included ‘ they look after the residents well’, ‘the staff are patient and work well with the residents – they deal with any awkward moments well’, ‘they always let us know if anything is wrong’, ‘the carers here are terrific and very receptive and show the residents a lot of affection’, ‘my relative is very well cared for’ and ‘my relative has been looked after fantastically’. Some relatives were noted to comment that they were looking for more feedback on care issues raised with management in the home. On discussion with staff, they talk about the residents in a caring and respectful way and are aware of the individuality of residents and their Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 12 differing needs. They also confirmed that they had been to training on maintaining residents privacy and dignity. A resident who commented said that ‘the staff are polite and talk to you nicely’. From the records and discussion with staff and visiting professionals, it is clear that residents’ healthcare needs are being met. Records show that residents have access to opticians, chiropodists and their GP in a proactive manner. The visiting District Nurses feel that the care and service at the home has improved over the last year and that the staff know the residents well. They also commented that they are used appropriately and confirmed that they are asked to assess residents for the risk of pressure sores. This concurs with resident records and residents are, where required, using pressure-relieving devices. This evidence concurs with the information provided by the manager in his AQAA. Risk assessments are in place for a variety of care needs. Staff should ensure that these are dated, as on some it was difficult to ascertain how old they were and whether they were an accurate reflection of the current risk. Records show that residents are weighed regularly and put on a monitoring sheet if there are concerns. If residents’ food and fluid intake are cause for concern, enough to be monitored, then the team needs to make sure that these are completed consistently in order to give an accurate picture for review/evaluation. The manager is about to introduce a nutritional risk assessment into the care planning system and a senior member of staff is taking the lead on this to ensure that all residents have been assessed and their care plans updated. A resident who commented said that ‘ you see your doctor quickly if you need to’. The administration of medication at the home was reviewed. A nomad and bottle to mouth system is in use. Medication administration records are maintained clearly and no omissions were noted. Medications are correctly checked in and where as and when medication is given, the reason is recorded. The deputy manager undertakes an additional checking system to audit for any anomalies. Controlled drug storage was checked and found to be in order, with appropriate records. Records show that residents have a mental capacity assessment to see if they can manage their medication and records show that regular reviews are undertaken. From discussion with the manager, he is very keen to ensure that residents are on appropriate and not unnecessary medication and is aware how some medications can adversely affect the wellbeing of residents with dementia. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive a good meal service and a range of activities, but the latter could be more suited to individual needs, in order to improve outcomes further. EVIDENCE: From discussion with the staff, routines of the day are resident led as far as possible. Staff confirmed that residents take differing amounts of time to help in the mornings if they want to provide the best care, i.e. in enabling residents to remain as independent as possible and to make their own choices regarding, for example, what clothes they may wish to wear. Staff acknowledge that this takes time and it can be tight at times with the current staff, to provide this level of input. One resident who commented said that ‘ I try to keep as independent as I can’. Relatives who commented said that ‘the staff always take time to communicate with my relative’. Residents were seen to be taking lie ins and expressing choices of when to get up. The manager employs two activity officers and they work during the week. On discussion with one of the activity officers and through records, it is evident a good range of activities are offered and this is not on a fixed rota, but depends on the residents and how responsive they are that day and who wants to join Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 14 in. It is clear from the records that some residents regularly take an active part whilst others do not. The assessment of individual needs in the relation to social stimulation could be more formally reviewed and based upon assessments linked, where possible, to objectives in the care plan, such as maintaining independence and promoting self worth, retaining a skill or interest. The development of ‘activities’ that promote self worth, such as helping with domestic tasks, gardening etc, could be developed further, as at the current time this is limited. Staff at the home regularly put on events and outside entertainers visit. The manager has also been employing a person to come and do exercises with the residents and this has proved popular. Families are invited to join in events and relatives spoken to on the day of the inspection confirmed this and commented positively on events attended. Relatives also commented that ‘ there is usually some-one in with the residents, either just with them, chatting or entertaining them, getting drinks etc’, ‘ they make a big effort to put on entertainment and do things to try and motive the residents’, ‘the exercise class on a Thursday is really good and the man who comes in is so good with the residents and they respond to him well’ and ‘ more outside activities in the garden would be an improvement’. The activities officer outlined the work that she has been undertaking with residents on their family and social histories and the reminiscence work that has led on from this. Records evidence that this is in place for some residents but not all. The staff have access to a lot of memory games and specialist books that can help with this process. Residents also enjoy music and singing, crafts, quizzes, reading and a knitting club has been developed. The manager writes a regular newsletter for residents and relatives informing them of upcoming events and information that they may need to be aware of. Information is available on advocacy services in the main entrance. At the current time no residents are using an advocate. The manager has been trying to develop more areas of the garden for residents to use this summer and relatives have been helping but the poor weather has limited the completion of this work. The manager hopes to have a summerhouse in the garden, which residents can use as a tea room and shop, making it another area of the home they can spend time in. Menus are displayed near communal areas, with choices evident; residents are asked during the morning what they would like and this was heard to be carried out in a respectful manner. Menu choices for residents are made easier for those with communication needs and picture cards are used to aid choice. The majority of residents take their meal in the main dinning room. Quite a few residents require a level of prompting to eat and staff were observed to be carrying this out in respectful way. Tables are nicely laid with tablecloths etc. and more glasses are available now with plastic beakers being used less, which is more dignified for residents. However, no condiments are on the table and no flowers etc, which would make for a more pleasant environment and promote independence. Three staff were seen to be in the dining area helping Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 15 with meals so this could be addressed. Residents were seen to have choices at lunchtime and staff were aware of personal preferences. Recent changes to menu have been made as colder weather sets in. Breakfast cereal choices are done visually for residents through putting the range choices in different bowls so they can choose. Relatives who commented said that ‘they have a fairly good choice of food and supper also has hot choice’ and overall relatives feedback to the home on the food service was positive. Residents who commented said that ‘ lovely meal today, nicely cooked’ and ‘ there is always a choice’. The cook at the home is completing healthy eating training at the current time. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be reassured that their concerns would be handled objectively and that residents are safeguarded, as far as possible, in the home. EVIDENCE: The manager has a copy of part of the home’s complaints procedure displayed in the main reception area. This only gives guidance on what to do if you are unhappy with the way that the home has managed your complaint and does not reflect what you need to do in the first instance. This was discussed with the manager. Records of recent complaints were reviewed and these were seen to be looked at in an objective manner and responded to appropriately and within 28 days. Relatives and residents can also raise concerns within group meetings and these were seen to be recorded in the minutes. It is recommended that these be logged in the complaints log, so complaints can be viewed as a whole and used, if needed, to improve the service that is provided at the home. Relatives, who commented in the last feedback questionnaire that the providers sent out, were positive overall about the availability of the manager to discuss problems, whether things get done that they ask about and whether they are involved with the affairs and matters at the home. This is positive. Relatives spoken to were aware of the relatives group and knew who to raise any concerns with. The manager in his AQAA states that ‘We ensure that Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 17 complaints procedures are properly and effectively implemented and the service users and their families feel confident that their complaint and concerns are listened to and acted upon efficiently. All written complaints are acknowledged within 14 days and dealt with in 28 days’. Staff spoken to were knowledgeable regarding the safeguarding of vulnerable adults but were not fully aware where all the associated policies and procedures to follow were in the home. These are in place at the home. No safeguarding referrals have been received since the last inspection. Staff training records show that there is nearly a 100 compliance for all staff at the home attending this training in either 2007 or 2008. This is positive. The manager is currently arranging training for key staff, including himself, on the Mental Capacity Act and also Deprivation of Liberty. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Areas of the home still require work to ensure that all residents live in a pleasant and safe environment. EVIDENCE: A partial tour of the home was undertaken with the manager. All the communal areas were seen and a good proportion of the bedrooms and bathrooms. Both floors were visited. Overall the standard of decoration in the home is generally good. Since the last inspection, some bedrooms have been decorated and new bedroom furniture purchased. The provider is steadily working through the home and the corridors are currently being redecorated. This is being undertaken by maintenance staff, who cover several homes. On touring the home it is clear that odd bits of maintenance work are not being attended to, doors off hinges etc. On talking to staff they are unclear where to record items that need attendance and the records seen were out of date. This needs to be formalised and staff made aware so that items are attended to Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 19 and that it can be assessed whether the level of maintenance provided in the home is sufficient. It is clear from comments receive on the last relatives feedback to the home, that it has been an issue whereby issues are reported and not attended to. See Management and Administration section. The manager undertakes the hot water temperature check and records show these are done regularly. Since last inspection the provider has installed new parts to the boiler and thermostatic valves have been changed. The manager in his AQAA states that ‘We will follow a continuous maintenance programme including redecorating of the entire home’. Some bed linen was noted to be worn and the manager assured us that this was due for replacement and a budget was available. Residents have good access to the large secure garden and most parts of the home. Residents enjoy having a view of North Weald airstrip, as they can watch the planes take off. Some outside areas of the home require attention as rubbish is not being stored appropriately and residents can look out on this, alongside old and broken equipment. This reflects poorly on the home. A review of the lighting in some of the back corridors is recommended to ensue the lux is sufficient to reduce the risks of accidents. The natural lighting is also not helped by trees at the back of the property that significantly darkens some bedrooms. This should be looked into to see if it can be addressed, making residents’ bedrooms a pleasant place to spend time. Overall the home was seen to be clean and minor odours were only noted in specific rooms where a management programme was in place. Staff need to be more careful not to leave residents personal items in bathrooms because of infection control risks. One resident who commented, felt that the cleaning was very good in the home and relatives spoken to concur with this. Fire safety equipment maintainence was checked and seen to be up to date. Some of the fire safety risk assessment was out of date with the manager being aware that he needs to do them. Testing of the fire alarm is not happening consisitantly and was last tested in June 2008. The last staff fire drill was recorded as June 08. This aspect of the home was discussed with manager as this needs to imporve in order to protect residents and staff. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be protected by robust recruitment practices and are cared for by a staff team that is well trained and committed to meeting their needs. EVIDENCE: During the past year there has been a notable turnover of care staff at Weald Hall. The manager reports that this is due to the isolated position of the home and therefore limited transport links and staff progressing in their careers. The home is able to offer some staff accommodation on the site. At the time of the inspection, the manager did not have any care vacancies and had not used agency staff for several months. The residents do benefit from a consistent core staff team, who from discussion, enjoy working at the home with the specialist resident group. Their comments included ‘ it’s a good team and nice atmosphere’ and ‘ the job is never dull and always different’. The manager assesses the dependency of residents to set the staffing levels. This he does from observation, discussion with staff and use of a dependency tool within the care planning system. The manager has also started to use an observational tool/audit that he has developed that monitors the wellbeing or ill being of residents with dementia. From records available the manager had completed approximately 8 of these audits and plans to use them more proactively in the future. From a review of the rota, it is not clear whether the Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 21 manager is always achieving his set staffing levels of 7 care staff in the morning and 6 in the afternoon/evening, as it is unclear, in some cases, what shift the member of staff has worked, as just the total hours worked are recorded. This should be addressed. Relatives spoken to commented that ‘ I visit everyday and I think that the level of staff is ok’ and ‘there is usually some-one in with the residents, either entertaining them or just being with them, chatting’. The manager, in his AQAA states that ‘We provide induction and 3 days paid training. We organise other training eg. POVA dementia, manual handling, health & safety, fire protection, NVQ, COSHH, infection control, medication, food hygiene and first aid etc’. From records and discussion with staff the evidence in the home concurs with this. The manager currently has 17 out of 29 care staff with an NVQ qualification of level 2 or above and these qualifications continue to be encouraged. Records show that a further 8 staff are currently enrolled on NVQ training. Staff spoken to were very happy with the level and type of training provided and commented that ‘ we have lots of training’ and ‘the training on respect and dignity was great and the oral hygiene course was also good’. The manager’s training matrix shows good compliance levels with food hygiene, infection control, adult safeguarding, fire safety, medication, and health and safety. The majority of staff are up to date with manual handling and although there are some gaps. The manager has addressed this by developing an in house trainer for this subject and the staff who need training updates are now booked on courses. In addition to statutory training it is good to see that 28 staff in the home, including ancillary staff have attended training on dementia and the care of people with dementia. Training has also been provided to 13 staff on dealing with challenging behaviours. Relatives commented that ‘the staff are patient and work well with the residents’ and ‘the staff deal with the awkward moods of residents really well’. The manager and senior staff at the home are due to attend training on Deprivation of Liberties and the Mental Capacity Act in the near future. It was disappointing to note that the manager has not attended an adult safeguarding training update since October 2004. Staff spoken to confirmed that they had received an induction linked to Skills for Care and records confirmed the induction and in addition further training, such as statutory training was provided during this period. The manager has robust recruitment procedures in place. Staff files were checked at random, for new staff and were found to contain all the required checks and documentation, including a CRB check and appropriate references and identification. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent and endeavours to run the service in the best interests of the residents. EVIDENCE: The registered manager has experience in care management and staff training. He has also attained qualifications in dementia related subjects and has completed the Registered Managers Award. He sits on safeguarding adults committees’ and the Mental Capacity Act and Deprivation of Liberty workgroups. Staff and relatives speak positively about him and comments include ‘ I find the manager and staff approachable’, ‘there is plenty of management support’, ‘the manager is approachable and very good with the residents’ and one resident said ‘ the staff are wonderful and the manager is Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 23 very good and helps anyway he can’. The manager holds staff meetings and the minutes show that these have both care and staffing issues discussed. The provider has developed a quality assurance system whereby relatives are asked to complete feedback questionnaires on a yearly basis and this is instigated by a regional manager rather than the manager of the home. No evidence was supplied to show that results are analysed and an action plan developed where required, however on individual questionnaires there was evidence of follow up by the manager of the home. The manager reported that 25 questionnaires were completed at the end of last year. Ten of these were reviewed. Overall feedback was positive regarding the care and services provided at the home. Comments included ‘since the new owners took over it is so much better, the staff now seem to know what they are supposed to do’, ‘it sometimes takes a lot of time to repair things in the home’, ‘ I am generally pleased with the care my relative has received in the year ‘x’ has been with you, my only criticism is perhaps in delays in getting minor repairs attended to, which I feel should be noted and reported by the staff’, ‘a very friendly and caring home’, ‘we are pleased with the laundry and the high standard of cleaning’ and ‘I am pleased with the improvements made to the care home over the past few months, more homely looking/improved decoration etc.’ The manager also stated that they are considering developing an internal audit based upon CSCI subject areas so they can ensure best practice as far as possible and since the last inspection have introduced an Admission Audit, as discussed in the section Choice of Home. The manager encourages relatives to manage resident’s finances and because of this only looks after a few accounts for people with no social support. The manager maintains clear records and is trying to ensure that residents are helped to have the best accounts for their savings. The manager has developed a supervision system. This consists of meetings and observational supervision. Staff spoken to confirmed that they had received supervision. Every month the manager has a subject for staff, to increase knowledge and this linked to supervision and consists of a questionnaire, procedural guidelines and facts to remember. Staff complete these and any issues that arise are feedback or followed up. Staff confirmed that this system is in place and subjects covered included nutrition. Records showed that supervision is taking place at regular intervals. A random inspection of safety and maintenance certificates for equipment in the home, were found to be up to date and in good order. Accident records were reviewed and found to be completed fully and where required, reported to the appropriate authority. Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 24 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 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 3 Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 25 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. Standard OP12 Regulation 16 Requirement Timescale for action 01/01/09 2. OP19 23 The activities programme in the home should be developed further so that individual needs are assessed and activities are provided, where possible, to promote residents’ independence and feelings of self worth. The home needs to have 01/12/08 sufficient maintenance support to ensure that issues noted are dealt with efficiently and systems need to be put in place that all staff follow, so that residents and staff live and work in a safe and pleasant environment. Fire safety equipment needs to 01/11/08 be tested at regular intervals and an up to date risk assessment should be in place to help ensure the safety of residents, visitors and staff in the home. 3. OP19 23 (4) Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 26 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. 3. 4. Refer to Standard OP1 OP3 OP15 OP16 Good Practice Recommendations The service user guide needs reviewing to ensure that it is provided in a suitable format for the resident group. A review of the admission assessment documentation, to make it more person centred, may be of value to lead into a person centred care planning system. The dining experience in the home should be reviewed so that residents’ independence is promoted. All minor verbal complaints/concerns raised in other forums should be logged as a complaint to give and overall picture in the home, so that the service can be improved where required. The outside of the home needs to be tidy to ensure that residents have a pleasant environment to live in. A review of the lux provided by the lighting and natural lighting to the rear of the home should be undertaken to see if it can be improved for the residents benefit. Further development of the quality assurance systems is needed so that analysis and action plans are available for interested parties, including relatives. 5. 6. 7 OP19 OP19 OP33 Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Weald Hall Residential Home DS0000070200.V371272.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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