Inspection on 15/12/05 for Winscombe

This inspection was carried out on 15th 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

Winscombe 12/06/06

Winscombe 14/10/04

Winscombe 03/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Winscombe Furze Hill Kingswood Surrey KT20 6EP Lead Inspector Denise Debieux Announced Inspection 15th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Winscombe DS0000013370.V258276.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. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Winscombe Address Furze Hill Kingswood Surrey KT20 6EP 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) 01737 362442 01737 362458 deanef@bupa.com BUPA Care Homes Limited Ms Frances Brenda Deane Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 6 (six) beds may be used for respite care. Up to 2 (two) beds may be used for post operative care for persons aged 21-65 years. 26th May 2005 Date of last inspection Brief Description of the Service: Winscombe is a purpose built single storey care home in secluded surroundings with landscape gardens and a central courtyard. The home is situated in a convenient location on the outskirts of Kingswood Village and provides accommodation and care for up to thirty older people. The three lounges and centrally located dining room are within easy reach of service users bedrooms. Each bedroom is single occupancy with its own wash hand basin. The home has ample bathroom and toilet facilities some of which are assisted. Car parking facilities are provided to the front of the building and the home is close to the train station and bus route. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs Chris Rajakariar (New Manager) and Mrs Debbie Inkersole (Regional Support Manager) were present as the representatives for the establishment. Prior to the inspection, survey forms were sent to the home and distributed to service users, with one being returned, to their relatives, with seven being returned, to GPs, Care Managers and health and social care professionals, with one being returned. The results of these surveys and comments made are used in this report. A tour of the building took place with twelve service users and nine on-duty staff being spoken with during the tour. The menus, care plans, staff rota, staff files and medication records were all sampled. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this inspection and the service users, their relatives and health and social care professionals who participated in the surveys. What the service does well: What has improved since the last inspection? The ongoing maintenance and redecoration of the home provides the service users with homely and comfortable surroundings in which to live. All service users now have signed contracts between themselves and the home. Winscombe DS0000013370.V258276.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. Winscombe DS0000013370.V258276.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 Winscombe DS0000013370.V258276.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): 2 and 6 Service users are provided with a written contract on admission to the home. The home does not offer intermediate care. EVIDENCE: At the previous inspection it was noted that some contracts had not been signed by the service users or their representatives and a requirement was made. This requirement has now been met with all contracts signed. Winscombe DS0000013370.V258276.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): 9 Policies, procedures and practices are in place to ensure the safe handling and administration of medication. EVIDENCE: The medication administration record sheets, medication storage, controlled drug storage and controlled drug record book were all sampled during this inspection and found to be accurate and well-maintained in line with the home’s policies and procedures and current legislation. At lunch-time, the medication round was observed and was seen to be carried out in line with the home’s policies and procedures. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 10 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): 14 Service users are encouraged and enabled to exercise choice and control over their lives. EVIDENCE: The routines of daily living are arranged to suit individual service users’ preferences and choices. This was confirmed by service users spoken with, with one service user adding that the ‘best thing about living here is being able to be independent.’ Service users are able to choose which activities they attend or participate in and the menus were seen to include two choices for the main meal each day. Service users handle their own financial affairs where appropriate. The inspector was advised that the home does not handle the financial affairs of any service users. The service users’ rooms seen all contained many personal possessions and were arranged to suit the service users’ wishes. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 11 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 EVIDENCE: Standards 16 and 18 were assessed and met at the last inspection and were not covered on this occasion. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 12 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 The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well-maintained with a pleasant and homely atmosphere. Some maintenance work is required in the garden to improve service user access and safety. EVIDENCE: All service users spoken with expressed their satisfaction with the accommodation provided in the home. One service user described how much she enjoys the gardens. During the tour of the home the premises were seen to be well maintained with service users able to access all areas. The gardens can be accessed, by wheelchair users, via the front doors but not all side doors. The inspector was advised that the home are exploring ways for this access to be improved. The paths around the garden have a build up of moss and the asphalt is uneven and cracking in places. The home have been asked to remove the moss and to carry out a risk assessment on the condition of the paths to ensure that service user safety and opportunity for independent access is not being compromised. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 13 Some concerns were raised to the inspector regarding the ramps provided at some of the fire evacuation points. A requirement has been made that the home consult with the local Fire Safety Officer for their advice and recommendations. On the day of inspection the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 14 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 The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. Action must be taken to improve the staff recruitment procedures to ensure that service users’ safety is protected. EVIDENCE: The home have achieved the target of having 50 of their care workers qualified to National Vocational Qualification (NVQ) level 2 in care or higher by 31st December 2005. Eight of the sixteen care workers have already achieved the qualification and one is currently on the course. Three staff files were reviewed and were found to contain the majority of the information required. However, the files seen did not include a full employment history and gaps in employment were not fully explained. One file did not have a reference from the person’s last place of employment with vulnerable adults and verification of the person’s reason for leaving previous employments was not always obtained. The home obtains two written references and applies for Criminal Record Bureau (CRB) checks for all staff. The requirement to put in additional measures when staff commence employment on the basis of a POVAfirst check whilst waiting for the CRB certificate to be returned and for the duration of a new workers induction was discussed. Requirements and a recommendation have been made regarding these areas of recruitment. The manager has recently obtained copies of the General Social Care Council (GSCC) code of conduct and practice for distribution to all staff at the home. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 15 All interactions observed between the staff and service users were caring and respectful. One service user told the inspector that the staff ‘are very good and kind.’ All relatives surveyed stated they were satisfied with the overall care provided and always felt welcome at the home at any time. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 16 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 and 35 There is a quality assurance and monitoring system in place that is based on seeking the views of the service users, but the home also needs to seek the views of stakeholders in the community. Policies and procedures are in place to protect service users’ financial interests. EVIDENCE: Service users views are sought on a regular basis. The home hold quarterly meetings with service users and relatives and an external company has just completed the yearly customer satisfaction survey. The inspector was advised that the results are being correlated and they expect the final report soon. Comment and suggestion cards are available in the front reception area for service users and relatives to use if they wish. A recommendation has been made that the views of GPs and other health and social care professionals are sought as part of the home’s quality assurance system. The home do not handle financial affairs for service users. However, on occasions when service users want valuables stored securely for a short period Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 17 of time, the home has a safe which can be used. Any items stored in this way are recorded in the service users’ files and service users or their relatives are provided with receipts. All interactions observed between the manager, staff and service users evidenced an open, positive and inclusive atmosphere. Winscombe DS0000013370.V258276.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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X Winscombe DS0000013370.V258276.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. 1 Standard OP19.5 Regulation 23(4)(b) Requirement Timescale for action 15/01/06 2 OP19.3 3 OP19.3 4 OP29.1-6 The registered person must consult with the local fire authority and verify that the ramps in place provide adequate means of escape from the home. 23(2)(o) The registered person must 09/02/06 arrange for the build up of moss to be removed from the paths in the garden. 23(2)(o) The registered person must carry 15/01/06 out a risk assessment and ensure that the external grounds are suitable for and safe for use by service users and are appropriately maintained. 15/12/05 19(1)(a-c) The registered person must not Schedule employ a person to work at the 2 care home unless the person is fit to work at the care home and he/she has obtained, in respect of that person, the information and documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, as amended by The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. DS0000013370.V258276.R01.S.doc Version 5.0 Winscombe Page 20 5 OP29.1-6 6 OP29 19(1)(a-c) The registered person must 15/02/06 Schedule obtain the information and 2 documents specified in paragraphs 1 to 9 of Schedule 2 of the Care Homes Regulations 2001, retrospectively for each member of staff employed by the company after The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 came into force on 26th July 2004. 18(2)(b) Where the registered person 15/12/05 (i-iii) permits a new worker to start 19(11) work with a POVAfirst check but (a-c) pending receipt of a valid CRB certificate and for the duration of a new workers induction training, the registered person must: • Appoint a member of staff (the staff member), who is appropriately qualified and experienced, to supervise the new worker. • So far as possible, ensure that the staff member is on duty at the same time as the new worker. • Ensure that the new worker does not escort service users away from the care home premises unless accompanied by the staff member. Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 21 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 Refer to Standard OP29 Good Practice Recommendations It is recommended that BUPA Care Homes Ltd review their employment application form to encompass the new requirements of Schedule 2 of the Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). E.G. request a full employment history instead of the past 10 years only; ask for reasons for leaving previous jobs; ask for gaps in employment to be explained; etc.. It is recommended that the home include the views of stakeholders in the community (i.e. GPs, Care Managers, chiropodist, therapists etc.) in their quality assurance system. 2 OP35.7 Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Winscombe DS0000013370.V258276.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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