Inspection on 25/05/05 for Weybourne

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 24/11/05

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 Announced 25 May 2005 00:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Weybourne Address Finchale Road Abbeywood London SE2 9AH 020 8310 8674 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Kent Community Housing Trust Beryl Richards CRH 40 Category(ies) of OP 20 registration, with number DE(E) 20 of places Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6/12/04 Brief Description of the Service: Weybourne is a Home for 40 older people 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 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 G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection and, in addition to the pre-inspection material provided, written responses were received from two health and social care professionals, six service users and eleven relatives. On the day of the inspection, several bedrooms were seen in addition to all the communal areas. The manager and at least five other staff were spoken to, and several service users were spoken with during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 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 G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 5 Residents who are admitted to Weybourne know that their needs will be met. Relatives are consulted and kept informed appropriately. EVIDENCE: The Home has exceptionally taken six new residents over the last two months. The manager has assessed the prospective residents to ensure their needs can be met in the Home, and residents are invited to the Home for lunch to see whether they like it. In addition the assistant manager will make observations of the resident to assess their compatibility with others in the Home. The Home produces a standard letter to the resident or his relative stating the Home’s ability to meet the assessed needs of the individual client. Additionally there is an induction checklist for relatives to alert them to the facilities offered, and familiarise them with the procedures in the Home. This is good practice. Visitors are welcomed at any time, and can see the residents in their room or in the small visitors’ room. All eleven relatives who answered the questionnaire said that they could see their relative in private. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8, 10 and 11 The health needs of residents at Weybourne are given high priority, and personal care is given with sensitivity and respect for the residents. EVIDENCE: Each resident has a plan of care that is followed by the care staff. District nurses and other health professionals come in to treat residents and advise care staff on procedures to be followed. During handover one member of staff reminded carers not to remove a dressing from a pressure sore. All six service users who responded to the questionnaire said that they were treated well and five out of six said that their privacy was respected. Staff were observed to be dealing discreetly with residents personal care. One lady coming in to lunch had been incontinent, and she was gently taken back to her room to change. Another resident came in to lunch with her dress tucked up at the back and a staff member unobtrusively tidied her skirt with a little word. A few residents have died since the last inspection and staff communicate this to individual residents as appropriate. The manager said that older people accept the fact of death, and some put small contributions towards a floral tribute sent from residents and staff. One care plan had recorded that the Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 10 family of the resident “would not want resuscitation in the event of a situation occurring”. It is recommended that statements such as this are dated and signed by the relevant family member, and countersigned by a member of the care staff who witnessed it to ensure there are no misunderstandings. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Residents have the opportunity to engage in a range of activities, and contacts with family and friends are encouraged. EVIDENCE: Weybourne is a very sociable Home where activities are seen to be important. A recent Provider’s report stated that the Home “never misses an opportunity to celebrate something”. A notice on the notice board announces that Weybourne won the inter-Homes Xmas Tree competition for their ‘Green’ tree with tree and decorations made entirely from recyclable materials. They recently organized a tea dance to commemorate the sixtieth anniversary of VE Day, and this was held in a local social club with invitations sent to other Homes in the area. The next event will be a picnic in the park at a monastery near Maidstone with the theme ‘Calamity Jane’. These events always generate photographs, which are then displayed for the residents. In house Bingo is also a popular activity and sometimes the residents are taken out to a local Bingo hall. Another theme of the Home’s activities programme is gardening, and their resourcefulness is demonstrated in that they have constructed a potting bench out of part of the stud wall from the old office to lay out grow-bags for pumpkins, marrows, strawberries and peppers. Other activities residents said they liked to do were to read, knit or sew. There were plenty of books in evidence. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 12 Residents eat in the newly enlarged dining room. The tables were set with a tablecloth, bright tablemats and a small posy of artificial flowers in the centre of the table. Music was playing in the background, and staff moved unobtrusively round delivering the meals, and bending down to make eye contact with residents to ask them what they would like to eat. The menus seen showed a range of typical English cooking, such as braised beef, ham, eggs and chips or lamb stew with pearl barley, but the cook said that she had responded to the wishes of some residents and had introduced more spicy dishes. On the day of the inspection there was a choice of sausage and mash or chilli and rice. One of the residents said, “We often choose what we want to eat”, and another said, “The food is very nice – lovely”. Relatives’ input is welcomed at Weybourne and the manager’s response to complaints and enquiries shows this. Relatives are to be invited to future Residents’ Forum meetings. In a recent Residents’ Forum meeting residents asked for jellied eels. The manager is therefore arranging a ‘Cockney evening’ to make an occasion of it. In addition to visiting, and all the relatives said that they were welcomed at any time, they can telephone, and if they alert staff in the office, their relative can be brought to the telephone room to receive a call in private. The Visitors’ room is to be set up with tea and coffee making facilities so that relatives can make themselves at home. Comment cards were issued to the Home prior to the inspection. The residential clients were given their own to fill in, and those in the dementia category were helped to complete them by a staff member. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 Complaints are dealt with promptly at Weybourne. EVIDENCE: New residents and their families are given a leaflet called, “Making your views known”, that tells them how to make a representation of there is anything they are unhappy about. The manager of the Home is very keen to resolve any issues in a timely fashion. The complaints log details the action taken, and outcome of the complaint, both signed and dated. In most cases the investigation was carried out the same day. The manager said that the three assistant managers have received training in dealing with complaints. All six service users who responded to the questionnaire said that they knew who to speak to if they were unhappy with their care, and eight out of eleven relatives were aware of the Home’s complaints procedure, although none of the eleven had had to make a complaint. During the inspection one lady came to say that she could not find two pairs of trousers and the manager told her they would ask if the items were in the laundry. Taking small complaints seriously shows residents that they are listened to and reassures them that more important matters would also be given due attention. All the service users spoken to on the day were happy with their care, and some considered they were fortunate to be in Weybourne. One lady said, “We haven’t been so lucky in our life”. Posters around the general election were distributed and postal votes were made available. Only two residents went out to vote. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 14 Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 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 standard(s) 19, 20, 24 25 and 26 Residents enjoy living in a comfortable and well-maintained Home. EVIDENCE: Since the last inspection, there has been some structural alterations at Weybourne. The manager’s office has been relocated in the small room opposite the main entrance, and the old office has been absorbed into the dining room creating a larger dining room. This was done, with the help of volunteers, over one day to minimise disruption for the residents. The result is a pleasing large dining room, which benefits the residents. The floor is to be sanded and sealed and this will improve the look of the room still further. Quarry tiles have been replaced in the laundry. One lounge area, known as the Harrod’s lounge is less popular, but a table and chairs given to the Home now means that the room is now utilised for craft activities, card games or flower arranging. Several bedrooms were seen and all had been personalised with items of furniture including, in one case, a leather armchair and a standard lamp. The Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 16 grandson of one resident had beautifully wallpapered her bedroom and this gave it a very individual stamp. All the rooms were well furnished, and the manager pointed out that the wardrobes are now secured to the wall to prevent them from toppling over. The Home was clean and tidy on the day of the inspection, and there were no odours in any area. Water tested in one bathroom was 48 degrees, and the manager made a note to inform the technician. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The Home is well-staffed by committed, caring and supported staff. EVIDENCE: The Home has one manager, three assistant managers and seven team leaders. This means that there is appropriate delegation of responsibilities across the Home. There is a large staff team with complementary skills and experience. Relatives say that there are always sufficient staff on duty, and they are satisfied with the overall care provided. Two staff members said that they work together well as a team, and individual comments from staff such as, “I love my job”, “You’re making the residents happy” and (speaking of the service users), “They’re like your own” attest to the personal qualities of the staff at Weybourne. This genuine and caring approach was observed during the inspection, when staff showed small gestures of affection such as rubbing their arm or a pat on the shoulder when speaking to residents. Feedback from other professionals was positive. One health professional said, “This is one of the most efficient homes with the most helpful staff that I visit”. During handover staff discussed different approaches to different clients, thus recognizing individual needs whilst offering consistency of care. The Home organizes its own recruitment. Personnel files were well-kept with documents in divided sections so that they could be accessed easily. All but one file looked at had a photograph of the staff member. All had a letter from the Human Resources Administrator stating that a satisfactory Criminal Records Bureau check had been undertaken. In one case the letter had been Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 18 endorsed by a manager stating that the original authorisation had been seen. A checklist confirmed that the authenticity of the referees had been verified, and it is suggested that the letter is signed and dated to confirm that this has been done. All staff are properly supervised. Another manager supervises the cook, who is the manager’s daughter to ensure fairness. Staff have an induction training in basic care, and ongoing dementia training. A member of staff who only started in February was clear about her role with residents and the ethos of the Home in seeking to reassure the residents and treat them as individuals. All staff are currently having end of year appraisals. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 38 The Home is well-managed and staff and residents benefit from the manager’s skill and experience. EVIDENCE: The manager is well liked by the residents and the staff. One staff member said, “She’s very fair. She listens”. Provider reports are done on a monthly basis and give a flavour of what it is like to live and work in the Home. At the last inspection it was noted that residents expressed a wish to be more involved in decision-making. This was brought up in a Resident’s meeting, and it was suggested that this be kept on the agenda. Again in the questionnaires that were returned prior to the inspection, two out of six service users said that they did wish to be more involved in decision-making, but it was not possible to ascertain in what way. It is recommended that this be explored further with residents to ensure they are fully consulted on their care and have appropriate input into the decision-making process. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 20 Health and safety have a high profile at Weybourne, and there are systems in place to safeguard the welfare of residents. An outbreak of diarrhoea and vomiting earlier in the year was appropriately notified to the responsible bodies and appropriate action taken to prevent the outbreak from spreading. One other incident involving a resident who became agitated and attempted to assault a member of staff should have been notified as an event affecting client wellbeing, and this is a restated requirement. One lady resident has a lock fitted on her door to prevent access from another resident. Wardrobes have been fixed to walls to prevent them from toppling, carpets were secure and there were handrails in every corridor. Photographs of the residents were on every door to aid orientation and help staff recognition. Maintenance and insurance certificates and records seen were up to date, and a report from the Environmental health on Food Hygiene and standards stated, “Premises very well run, very good systems and procedures in place”. The manager reported that a new risk assessment tool setting scores for severity against probability was proving too difficult to use, and a new format was being devised. This indicates that staff see recording not just for its own sake, but also as a tool in maintaining and improving standards of care in the Home. Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 4 3 x x 3 3 x x x x 4 Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19(4)(b) and (c) Requirement Staff records should contain the documents as specified in SChedule 2, and there should be a written endorsement that references have been verified (previous timescale 17/1/05 not met) The Registered Person must give notice to the Commission of any event in the Home that affects the well-being or sfatey of any service user Timescale for action 12 August 2005 2. OP38 37 Ongoing 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 OP11 OP33 Good Practice Recommendations It is recommended that any statements concerning the care of dying residents are signed, dated and witnessed to ensure there are no misunderstandings It is recommended that residents are consulted formally about their care, and, where possible, have input into the decision-making process Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup kent DA14 5RH 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 Weybourne G51G01s6862Weybournev221060.25.5.05stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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