Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 19/09/05 for Winthorpe Hall Care Home

Also see our care home review for Winthorpe Hall Care Home for more information

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A well-maintained and clean environment is provided. There is a choice of large bedrooms available. Service users` needs are assessed and comprehensive care planning is in place.

What has improved since the last inspection?

Since the last inspection on 20/07/05 care planning has developed and a trainee manager has been appointed.

What the care home could do better:

The care plans are available only by viewing on computer and would be more easily accessed if printed. Some people may require them in larger print and the provider should make them accessible to service users in an appropriate format. Medication procedures must be followed more closely and appropriate records of the amount of controlled drugs must be kept. There are already plans to improve the choice of meals available and the menu is currently being revised. Printed menus should contain choices at every meal. One area where improvement is essential is with recruitment procedures. New staff have not been checked through the Criminal Records Bureau and this must be done to ensure service users are protected. No further new staff are to be appointed before checks are made and applications must be made for those existing staff who have not been checked. The Commission will monitor progress with this.

CARE HOMES FOR OLDER PEOPLE Winthorpe Hall Care Home Gainsborough Road Winthorpe Newark Nottinghamshire NG24 2NR Lead Inspector Meryl Bailey Unannounced Inspection 19th September 2005 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Winthorpe Hall Care Home DS0000024670.V250041.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. Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Winthorpe Hall Care Home Address Gainsborough Road Winthorpe Newark Nottinghamshire NG24 2NR 01636 701826 01636 701234 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) Mr R C Pountney ** Post Vacant *** Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration of 1 Named Service user within the category TI Date of last inspection 20th July 2005 Brief Description of the Service: Winthorpe Hall is a care home registered to provide personal care and accommodation for up to 34 older people. The home is privately owned and is situated within a small village, just north of the market town of Newark. Major road networks are located a mile away and there is a local bus service into Newark. There are a small number of amenities available within the village itself. Winthorpe Hall is a spacious, converted and extended building providing accommodation on three floors, to which a passenger lift aids access. The main lounge areas and dining room are on the middle floor and smaller sitting areas are on the ground floor. Entrances are accessible to wheelchair users. Bedrooms are spacious and some offer ensuite facilities. Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by one inspector during one day. There were 20 service users in residence. Some service users, visitors and staff gave their views about the care provided and discussions were also held with the registered provider. Three care plans were examined and other records have been used to assist this inspection. Most communal areas of the home were inspected and a sample of bedrooms was also seen. What the service does well: What has improved since the last inspection? What they could do better: The care plans are available only by viewing on computer and would be more easily accessed if printed. Some people may require them in larger print and the provider should make them accessible to service users in an appropriate format. Medication procedures must be followed more closely and appropriate records of the amount of controlled drugs must be kept. There are already plans to improve the choice of meals available and the menu is currently being revised. Printed menus should contain choices at every meal. One area where improvement is essential is with recruitment procedures. New staff have not been checked through the Criminal Records Bureau and this must be done to ensure service users are protected. No further new staff are to be appointed before checks are made and applications must be made for those existing staff who have not been checked. The Commission will monitor progress with this. Winthorpe Hall Care Home DS0000024670.V250041.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. Winthorpe Hall Care Home DS0000024670.V250041.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 Winthorpe Hall Care Home DS0000024670.V250041.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): 3 Needs of new service users are appropriately assessed. EVIDENCE: Assessments from social services have been received prior to admission of residents and further assessment has taken place as part of care planning – see Standard 7. Winthorpe Hall Care Home DS0000024670.V250041.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): Comprehensive care plans are in place, but not readily accessible to service users. External professionals are involved in meeting health needs. Current medication administration practices do not provide sufficient safeguards against errors being made. EVIDENCE: There is a plan of care in place for each service user and all plans are accessible via a computer only and with the assistance of one of the senior care staff. Three plans viewed on screen were found to be comprehensive. None of the service users or their representatives have seen or signed copies of the care plan, though there were some signatures on files of agreement to having cot sides in place. It is recommended that the plans be printed so that they can be viewed more easily and signed. The provider has maintained that the care plans are accessible in their present form. The content of the action plans gave clear instructions to staff of how to meet identified needs. Also, there was evidence that service users had been consulted in drawing up the plans as their wishes were included. However, it was not clear if all staff were fully aware of the content of all plans. One plan stated that a service user required a special spoon for eating, but in practise a member of the care staff was observed feeding this person. Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 10 There was evidence of visits from district nurses and general practitioners and some service users had recently seen an optician. Medication was stored securely and a trolley was used to transport medication around the home. One staff member was observed signing the record sheet prior to administering tablets. All staff must be reminded that signing the sheet is confirmation that the medication has been taken. Increased security was available for controlled drugs and these were prescribed for two service users. There was a record of signatures for these having been administered, but no indication that they were counted. A controlled drugs register must state clearly the precise number of these drugs that are held in the home for each service user. Winthorpe Hall Care Home DS0000024670.V250041.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): 13 and 15 Relatives feel welcome to visit. EVIDENCE: Social contacts and next of kin are recorded within care plans. There were several visitors during the afternoon of the day of this inspection. Some contributed their views to this inspection. They generally felt welcome to visit at any time. The lunch meal available consisted of quiche, potatoes and vegetables, followed by jelly and ice cream. There was a choice of the flavours of jelly and ice cream. The cook said that at admission each service user was asked about their likes and dislikes so that alternatives can be given if people do not like particular meals. As at the last inspection, the menu was in the process of being revised and the draft menu showed more choice and variety. It was planned to have the menu on display on each dining table and it is recommended that alternatives always be written on the menu. There was a good stock of food in the freezer and in the pantry. Most stocks were organised and labelled, though a recent delivery of meat required labelling. Part of lunchtime was observed and most service users were satisfied with the meal provided. One person was served in the bedroom, but the majority sat in a spacious dining room. Later another person was assisted with the meal, whilst in a recliner chair in a lounge. The care staff assisting was seated on Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 12 the arm of the chair and leaning over the person. It is recommended that staff sit at the same level as those they are assisting. Winthorpe Hall Care Home DS0000024670.V250041.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): Service users and relatives are not fully aware of the complaints procedure and are not all confident that a complaint would be acted upon. EVIDENCE: No records of recent complaints were seen. The commission received an anonymous call from a relative who had raised concerns with the provider and was not satisfied with the response received. This relative did not want to formalise the complaint, but the concerns raised regarding medication, meals and cleanliness have been addressed within this inspection. Other relatives present on the day of inspection said that if they were unhappy with anything they would talk to senior staff, but neither they, nor service users spoken with, were aware of the full complaints procedure. Winthorpe Hall Care Home DS0000024670.V250041.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 building is well maintained. Bedrooms generally suit the needs of service users and the home is kept clean and hygienic. EVIDENCE: The premises consisted of a large stately house that has been adapted and extended. Accommodation was arranged on three floors and a passenger lift was provided. The main lounge areas and dining room were on the middle floor and smaller sitting areas were on the ground floor. A variety of chairs were provided and service users had a choice of where to sit. The dining room was spacious with plenty of room for all service users. All areas used by service users were well maintained and decorated. Bedrooms were available on each of the three floors. Rooms within the extension had ensuite facilities. Only one room on the top floor was occupied, though others were prepared for any prospective service users. One service user stated that it often felt cold in the mornings and the heating was not controllable. This was found to be the case only in the extended part of the building as the covers prevented easy access to the controls on radiators. The Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 15 owner stated that it was possible for the thermostat on the radiator to be adjusted and that this would be done. Generally, service users said they were satisfied with their individual rooms. Cleaning was in progress and most areas had been cleaned. Visitors said that the premises are always clean and odour free. Winthorpe Hall Care Home DS0000024670.V250041.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): 27 and 29 Sufficient staff are employed, but recruitment procedures do not protect service users. EVIDENCE: There were three care staff, which was sufficient for the number of current service users. A Senior Care staff is always on duty to take responsibility for medication and management hours are additional to care hours. The owner stated that he has not requested Criminal Records Bureau checks for the last seven staff to be recruited. The reason given was the importance of staff commencing employment immediately as well as the cost of the checks. The new Protection of Vulnerable Adults First checks (PoVA First) can be carried out prior to waiting for the full Criminal Records Bureau check to enable people to start work. Application for both types of check should be made at the same time. The result of PoVA First checks must be received before any new staff commence and existing staff without checks must be closely supervised until full disclosures are received. The records of two staff were checked and in addition to the lack of Criminal Records Bureau disclosures, one did not have references. Winthorpe Hall Care Home DS0000024670.V250041.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 There is no registered manager. EVIDENCE: There was an acting manager but she was not registered with the Commission as manager. A new trainee manager has been appointed, but was not ready to take over as manager. Application must be made to the Commission for a manager to be assessed as fit for registration. Winthorpe Hall Care Home DS0000024670.V250041.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13(2) Requirement Ensure all staff follow correct procedures when administering and recording medication including controlled drugs. Supply a written copy of the full complaints procedure to every service user and to any person acting on behalf of a service user. Keep a record of the final outcome and action taken in respect of all concerns raised and formal complaints. Two satisfactory references and the result of a PoVA First check must be received before any new staff commence in employment. Provide evidence of enhanced checks through the Criminal Records Bureau in respect of all existing staff. Staff without checks must be closely supervised until disclosures are received. Application must be made to the Commission for a manager to be assessed as fit for registration. Timescale for action 19/09/05 2 OP16 22 19/10/05 3 OP29 19 and Schedule 2 19 and Schedule 2 19/09/05 4 OP29 19/11/05 5 OP31 9 19/11/05 Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 20 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 OP15 Good Practice Recommendations Provide printed care plans so that they can be viewed more easily and signed by service users or their representatives. Provide alternative meal choices on a printed menu so that service users are aware of those choices. Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Winthorpe Hall Care Home DS0000024670.V250041.R01.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!