Inspection on 24/11/05 for Weybourne

This inspection was carried out on 24th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Weybourne 20/01/09

Weybourne 21/12/07

Weybourne 27/02/07

Weybourne 25/05/05

Weybourne 06/12/04

Weybourne 02/07/04

Weybourne 25/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Weybourne Finchale Road Abbeywood London SE2 9AH Lead Inspector Sue Grindlay Unannounced Inspection 24th November 2005 09:15 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 Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Weybourne Address Finchale Road Abbeywood London SE2 9AH 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) 020 8310 8674 Kent Community Housing Trust Ms Beryl Richards Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Weybourne is a Home for 40 older people that is run by Kent Community Housing Trust. The Home specialises in the care of people with dementia, and the bulk of the service users are in this category. The Home does not provide nursing care, but health professionals visit the Home on a regular basis. The Home is a purpose-built unit on two floors in Abbey Wood. There is a parade of shops nearby, and Abbey Wood Station is a short distance away. There are thirty-three rooms on the ground floor and a further seven on the first floor. Seven rooms have ensuite facilities. There are four lounge areas, a large dining room, a small visitors room and a central courtyard garden that has flower beds designed for colour and scent. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection over five hours, and was the second inspection of the inspection year. Key standards not addressed in the first inspection were covered, and issues that were raised in the person-in-control visits and the contract monitoring visit in June were also revisited. The manager and three staff members were seen, and a number of service users were spoken with. An unescorted tour of the building was made, and lunch was sampled. No visitors were seen on this occasion. What the service does well: What has improved since the last inspection? What they could do better: Increased staffing levels would ensure that residents had greater one to one attention. Staff records must be audited to ensure they have all the relevant documentation. Notwithstanding budget constraints, refurbishment is slow, and promised improvements take time to materialise. Health and safety matters must receive attention at all times. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 6 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. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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): 6 This standard is a key standard, but the Home does not take intermediate care clients. EVIDENCE: The manager stated that respite has occasionally been offered if there was a spare bed, but this is not routine practice. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 11 Service users’ individual health and personal care needs are met. EVIDENCE: Care plans are reviewed on a monthly basis. Service users are encouraged to participate if they are able to do so. Some are content to leave decisions to their family. A new assessment tool has been devised, and this is in a more accessible format. One moving and Handling assessment stated, “No Risk at Present”. Another was left blank, but signed and dated. It is recommended that where the assessment has determined there is no risk, this should be clearly stated on the risk assessment sheet (Recommendation 1). The Home’s nominated G.P. has given notice, so all 29 service users have to be re-registered at the end of the year. The manager has been proactive in seeking assistance from the Primary Health Trust, and it is hoped that a new G.P. within walking distance of the Home, will be identified as soon as possible. This is now subject to a requirement (Requirement 1). No service users self-medicate. One service user’s medication has been reviewed, and an amended dosage means that he is more stable. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 10 One service user’s file contained a clear request from the family not to send the service user to hospital without consultation, unless for a break or stitches. It is recommended that the family be asked to put this in writing, or sign a consent form on the resident’s file (Recommendation 2). Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15 Staff at Weybourne provide a stimulating and homely lifestyle for the residents. EVIDENCE: Weybourne sets store by its daily activities and social events, and there is always something going on. The activities for the day were skittles in one lounge, and Christmas collage activities in another. Two service users were playing cards in the smoking lounge. There has been a move towards small group activities or one to one engagement, in line with dementia care. In the summer some residents attended an event with a Calamity Jane theme. They had a cockney night, with a visiting pearly King and Queen, pie and mash, eels and cockles and a sing-along. A large screen television has been purchased for the dining room, and residents were treated to a film night with ice cream cartons to add to the atmosphere. Christmas parties, visiting theatre groups, and a local school coming to see carols are part of the proposed Christmas entertainment at Weybourne. One lady said that she enjoyed going to church on a Sunday, and her care plan reflected this lifelong interest that she was till able to pursue. Several residents enjoyed watching people passing by, and this connection with the outside world is important to maintain. This standard is exceeded once again. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 12 The small visitors’ room on the ground floor is now set us with tea and coffee making facilities and a small fridge for milk. This creates a homely feel for visiting families who can see the resident in private. The manager’s office is visible from the main entrance to the Home, so she can welcome visitors personally and they know who she is. All the bedrooms seen had evidence of personal artefacts, including ornaments, pictures and some items of furniture. One had a framed poem, “To Granddad”. One resident had recently been admitted with her two cats, and this was being trialled to see if it could work as a permanent arrangement. The cats had made themselves at home in the Harrods lounge, and the lady’s obvious delight in them vindicated the manager’s decision. The record of the Residents’ Forum Meeting that took place on 9/9/05 states, “All residents stated that they are happy with their meals and enjoy the variety”. The social aspect of food and food enjoyment is well recognized at Weybourne and appropriate food is provided for themed events. The meal on that day was roast chicken or Cornish pasty with potatoes, cabbage and carrots. The chicken was sampled, and it was tasty. It had been deboned and was cooked in gravy, so it was manageable for the residents who all ate unassisted. There was no menu to be seen, and staff said that normally it is written on the white board adjacent to the servery hatch. Some residents were asked if they knew what the meal was, and they did not know. One said, “I like the surprise”. However, it is recommended that there is some visual cue to the meal so that residents can anticipate what they are going to have, build up an appetite and have time to make their choice. Ideally this should be done pictorially, and could be on menu cards on the table, or at eye level on the wall outside the dining room (Recommendation 3). Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Complaints are dealt with promptly and efficiently at Weybourne. EVIDENCE: The Home’s complaints log records three complaints since the last inspection. The log gives space to record who is investigating the complaint, and the date it was dealt with. The complaints details sheet gives space for more information including whether the complainant was satisfied. Also seen were six undated thank you cards. None of the service users spoken to had any grumbles at all about the care they received. One said, “You couldn’t argue about anything”. The Home has a whistle blowing policy. The manager has had training in POVA and this has been cascaded to other staff. During the inspection there was a visit from the Lord Chancellor’s visitor, who visits clients subject to the Court of Protection matters in order to check the financial arrangements that are in place. She said that the records she had seen relating to her client in Weybourne were well kept and up to date with, “an apparent and appropriate spending pattern, plenty of toiletries in her room and appropriate clothing”. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 the following standard(s): 19, 24 and 26 The Home is comfortable and well maintained. Some refurbishment is overdue. EVIDENCE: Bedroom doors have been repainted. A large tree in the garden has been lopped to prevent any danger to residents. There is close circuit television covering the outside of the building, and a television monitor in the duty office. Bedroom doors have a name and photograph on them to help residents’ orientation. Some signage was seen on toilet doors, but this was not pictorial, and it is recommended that some pictorial signs be devised to indicate toilets and bathrooms (Recommendation 3). The dining room was extended earlier this year, but the work has not been completed, as the floor remains unfinished. It was to be sanded and resealed. A quote for the work has been obtained but it is considered that to be necessary not only for hygiene purposes but to improve the look of the environment, so this is a further requirement (Requirement 2). The carpet in the telephone room was not fixed. It was in two pieces and the leg of the chair had pulled up the edge of one of the pieces. This could present a tripping hazard. This is a further requirement (Requirement 3). Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 15 All the bedrooms seen were clean, tidy and well furnished with a number of personal items on display. Following the contract monitoring visit in June, when some of the commodes were said to be worn, the manager has 24 new commodes on order. Also on order are new bedside tables with a lockable drawer for safekeeping of personal items or items of value. The Contract Monitoring visit report also noted a bad odour in the entrance to the Home, and this was noted also on the day of the inspection. There was an odour also in the upstairs corridor. The manager said that the carpets are routinely cleaned but the smell does not go away. She is proposing replacing the caret in the main entrance lobby with a washable, laminate flooring, and this might reduce the problem. The Contract Monitoring visit report also recommended installing a door between the laundry corridor and the walkway to the kitchen. This would prevent cross contamination, and would protect service users who might stray into the kitchen area. The Person in Control report dated 24/10/05 said that work would commence on this “in the immediate future”. Notwithstanding budget constraints, this means nearly six months have elapsed before these improvements are actioned. This is subject to a recommendation (Recommendation 4). In her Action plan to the Contract Monitoring visit the manager of the Home states that she had discussed with Assistant managers, care staff and the domestic team the importance of locking doors after use. The door to one sluice room was unlocked, and this is a further requirement (Requirement 4). Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29 Staff receive appropriate training, but information on staff must be available in the Home. EVIDENCE: The latest Person-in Control report dated 24/10/05 states that three new staff have commenced their NVQ2 and the Home has achieved an 82 result, which is very commendable. This standard is therefore exceeded. Four staff files for newer employees were checked. The files were not in order, and some sections were empty. One had a checklist at the front, which is a good idea to show whether all the documentation is present. Two had no photographs, and these were put on file during the inspection, all had at least one form of identification, three had two references, and one only had one. It was not clear whether the references had been verified. One had evidence of a criminal records bureau check and two had evidence of POVA First enquiries. Only one had a health declaration. A restated requirement has been made about information that must be available in the Home for each employee (Requirement 5). Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 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): 33, 35, 36 and 38 The Home is well-managed and staff and residents benefit from the manager’s skills and experience in the field. EVIDENCE: Since the last inspection only two Person-in Control reports have been received at the Commission, one dated 26/5/05 and one dated 24/10/05. The Home had an additional visit report for June. Unannounced visits should be made at approximately monthly intervals, and a copy of the report made available to staff in the Home as well as a copy being sent to the Commission. This is a requirement (Requirement 6). Service users are spoken to every day, to ensure they continue to be happy with their care, and key worker duties include consultation as a key task. A Quality Assurance questionnaire was sent out to relatives in the summer, and was analysed at the Human Resources department. The manager did not know the outcome of this, and this would seem to defeat the object of the exercise. It is therefore recommended that the results of any consultation with families be published as soon as possible Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 18 after the research has been done, with clearly stated results and recommendations for action if necessary (Recommendation 5). The Home prefers not to hold valuables for any resident. Any such items would be included on the property sheets in the residents’ file, and family members asked to take things away would be asked to sign to say that they had received them. The manager was on the working party that devised a staff review record, and she is keen to promote training for her staff. The staff review record is used in annual appraisals and also during supervision when it provides a tool for discussion. Targets are set and reviewed at regular intervals. The manager said that supervision takes place at approximately every two months. No supervision records were looked at on this occasion. An unfortunate event in another Home has raised issues of safety and security for all the Homes run by Kent Community Housing Trust. A new procedure has been devised for night working, and this policy, which is in draft, includes hourly checks of all fire doors and possible exit routes from the building, and discreet hourly checks on each resident. All these checks are logged on a record sheet for the night. If a service user of member of their family objects, then their wishes not to be disturbed can be recorded on the care plan. Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 X 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 X 3 Weybourne DS0000006862.V259925.R01.S.doc Version 5.0 Page 20 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 OP8 Regulation 13(1)(a) Requirement The Registered Person should make arrangements for service users to be registered with a general practitioner of their choice. The Registered Person is required to inform the Commission of progress in this area. All parts of the Home should be kept clean and reasonably decorated, specifically the floor in the dining room should be sanded and sealed, for hygiene purposes and to enhance the look of the dining room. The Registered Person should ensure that all parts of the Home to which service users have access are free from hazards to their safety, specifically the carpet in the telephone room must be secured to the floor to prevent tripping hazards. Unnecessary risks to the health or safety of service users should be identified and so far as possible eliminated, specifically the doors to the sluice rooms must be locked when not in use. DS0000006862.V259925.R01.S.doc Timescale for action 11/01/06 2. OP19 23(2)(d) 11/01/06 3. OP19 13(4)(a) 11/01/06 4. OP26 13(4)(c) 11/01/06 Weybourne Version 5.0 Page 21 5. OP29 19(4(b) and (c) 6. OP33 26 Staff records should contain the documents as specified in Schedule 2, and there should be a written endorsement that references have been verified (Restated requirement previous timescale 12/08/05 not met) Reports should be made monthly by a responsible individual, a copy retained in the Home and a copy sent to the Commission. 11/01/06 11/01/06 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 OP7 OP11 Good Practice Recommendations Where the risk assessment determines that there is no risk from a stated activity, it is recommended that the assessment states this. It is recommended that any statements concerning the care of dying residents are signed, dated and witnessed to ensure there are no misunderstandings. This is a renewed recommendation. It is recommended that menu cards, especially pictorial ones, are produced to offer residents some anticipation of the meal that is to be offered, and the choice within that meal. It is recommended that improvements to the environment, especially those relating to hygiene, infection control and safety to residents are actioned without delay. It is recommended that the results of any consultation with relatives be published as soon as possible after the research has been done, with clearly stated results and recommendations for action if necessary. 3. OP15 4. 5. 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