Inspection on 10/12/05 for Winchley Home

This inspection was carried out on 10th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Winchley Home 27/02/07

Winchley Home 28/07/05

Winchley Home 21/12/04

Winchley Home 26/07/04

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

CARE HOMES FOR OLDER PEOPLE Winchley Home Rectory Lane West Winch Kings Lynn Norfolk PE33 0NR Lead Inspector Mr Christopher Handley Unannounced Inspection 10th December 2005 03:15 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 Winchley Home DS0000027342.V272171.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. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Winchley Home Address Rectory Lane West Winch Kings Lynn Norfolk PE33 0NR 01553 841582 01553 842270 gemini@winchley.wanadoo.co.uk 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) Gemini Care Limited Mrs Gina Reeve Care Home 41 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (31) of places Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is regsitered to accommodate forty-one (41) Service Users in total of whom ten (10) may be Older People with Dementia. The remaining Service Users can be Older People not falling into any other category. 28th July 2005 Date of last inspection Brief Description of the Service: Winchley Home is a registered care home providing care for 41 people, 10 of whom have dementia. There are 31 single rooms and 5 double rooms. The home is maintained to a high standard both internally and externally. The home has pleasant views over the front garden. There is good access to the home, which has a large car park at the front of the home. The gardens are a feature of this home. The home receives its nursing and medical care from the local Health Centre. The home is located in the village of Winchley situated on the A10, four miles from Kings Lynn. Winchley Home DS0000027342.V272171.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 and was carried out on Saturday the 10th December, following the receipt of a complaint which stated; • • • The complainant has had difficulty getting into the home. Was admitted by an elderly gentleman, who disconnected the door alarm with ease. The staff were in the kitchen, one of whom was sitting on the worktop, no one was on the “shop floor”. The inspection commenced at 3.15pm and was completed at 4.45pm. Three residents, two visitors and four members of staff were interviewed. The Inspector undertook a brief tour of the home and look at supporting documentation. No evidence to substantiate the complaint was found at this inspection; staff were busily engaged caring for residents. The manager has been asked to investigate further. What the service does well: What has improved since the last inspection? • The environment of the home. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 6 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. Winchley Home DS0000027342.V272171.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 Winchley Home DS0000027342.V272171.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): None of these standards were inspected. EVIDENCE: Winchley Home DS0000027342.V272171.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&9 The resident’s lifestyle and pattern of day are set out in their care plans. The medicine system is safe and effective. EVIDENCE: All residents have an individual care plan, which are clearly marked confidential. They are stored securely and kept safe in the office. Each care plan has the essential elements of Assessment, Plan, Implementation, and Review. The plans describe the chosen routines of the resident’s day e. g getting up and retiring. The plans of the three residents interviewed were read and this confirmed what they had told the Inspector. The entries in these documents are dated, legible, and signed. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 10 Miss Chipalo told the Inspector that she had had administered the midday medicines. She, and all other staff who administer medicines in this home have had training for this. Miss Chipalo showed the Inspector the medicines. The medicines are kept in a locked trolley, which is kept in a locked room. The home has Monitored Dosage System. There are good records of administration with clearly written initials of staff and no crossing out. The cassettes were neat and tidy. Medicines are regularly reviewed Miss Chipalo said. There were no loose or unaccounted for medication. There are Controlled Drugs in the home, which are kept in a Controlled Drug cabinet. One of these medicines was counted and found correct against the register. The home enjoys a good relationship with the supplying pharmacy. The home has a medicine procedure, which has been seen by the Inspector. Based on what was seen it is apparent that the system is safe and effective and Miss Chipalo has a sound knowledge of the medicines and the system used. Winchley Home DS0000027342.V272171.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 Residents find the lifestyle matches their expectations and preferences. Residents maintain contact with their relatives. EVIDENCE: The Inspector spoke to three residents who were sitting in Jasmine lounge quietly talking. The Inspector introduced himself to them. They described their day, and said that they got up in the morning when they chose and retired at night when they choose. One resident said that he always got up at 6am as he had done all his life. Their choices were confirmed in care notes read. They spoke highly of the staff who were very helpful, very courteous and always looked smart. The Inspector can confirm the latter, as all the staff on duty appeared very smart in their white tunic tops and dark trousers. There were no residents in bed. Residents were having a quiet Saturday afternoon. Most were in the lounges, some watching TV, others quietly talking to each other, or members of staff, or their visitors. Others were reading the papers or magazines. Some were in their rooms. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 12 The Inspector introduced himself to two visitors who were just leaving having visited their relatives, and briefly interviewed them. They said that there was always enough staff on duty, there was always staff about. Staff were always very helpful and always looked smart. They said that the meals were very good and that their relatives were very happy in the home and with the care given. They finally said that thy were very pleased to see that Inspectors carried out un announced inspections of homes, and said that they found this reassuring, as care was being monitored. Winchley Home DS0000027342.V272171.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): None of these standards were inspected. EVIDENCE: Winchley Home DS0000027342.V272171.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 Residents live in a home which is safe, based on the training of staff. There is a well maintained environment. EVIDENCE: All staff have had training in fire prevention and three members of staff when asked by the Inspector very clearly described what action would be taken in the event of fire. Judging from their very positive responses they have very good knowledge of this important procedure. Fire Prevention training forms part of the induction of staff and is regularly updated. There are smoke detectors in all rooms and corridors. The corridors, fire doors, and fire exits, were free of any obstruction or clutter. There were no wedges seen under any doors. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 15 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): 27 There were adequate numbers of staff on duty with the skills to meet the needs of residents. EVIDENCE: There were five experienced staff on duty, plus one new member of staff who was working in a supervised capacity. The Senior Carer on duty, Miss Chipalo was in charge at the time at the time of the inspection. Miss Chipalo has NVQ 3, and trained as a nurse in Zambia. Miss Chipalo has worked at the home for one year and eight months and is familiar with the practices and routines of the home. Three other members of staff have NVQ training and have worked at the home for some time. Other training provided includes Induction and Foundation training, which meets NTO specification Fire prevention, Moving and Handling, First Aid, Infection control, Diabetes Awareness, Funeral Awareness, Food Hygiene, Care Planning training, Communication and Confidentiality, Adult Abuse prevention, Health and Safety, Equal Opportunities and Rights and responsibilities. The supernumery member of staff is undergoing her induction training and is a trained midwife in her home country of Poland. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 16 The staff on duty agreed with the rota which was seen by the inspector. The rota is clearly written, well set out, and easy to follow. It shows who is on duty, who is in charge and who is on call. The staff on duty agreed with the rota. The on call arrangement and back up arrangements are very clearly written on the rota and were seen by the Inspector. Miss Chipalo is authorised to call staff in if needed from a list of staff. Miss Chipalo would seek advise from the person on call if there were an accident, fire, or other major event which might need back up. Miss Chipalo was asked what action she would take if she saw a visitor who was unknown to her walking through the home. She replied that she would ask them “Can I help you?”, firstly from the point of view that this is a large building and people may not be familiar with the layout of the home. Also from the security point of view, as she is conscious of the need for security in the home. The two Senior Carers from either end of the home would give handover information to Miss Chipalo, and then she would give the hand over to the Senior Carer who was to come on at 5.30. Winchley Home DS0000027342.V272171.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): 31 The home was being managed by a competent and capable person at the time of the inspection. EVIDENCE: This was the first time that Miss Chipalo had assisted in an inspection and was understandably nervous, yet she handled the process very well. She has sound knowledge of the practices of the home, and has a good range of training. She is observant and courteous. She knows when to seek advice and from where she can obtain this. Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Winchley Home DS0000027342.V272171.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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