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Inspection on 20/07/05 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 20th July 2005.

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

Winthorpe Hall has a relaxed, welcoming and friendly atmosphere. Service users spoken with expressed their needs are met, staff are very nice and individuality is respected. The environment is well maintained and service users benefit from the use of the large mature gardens and the unique features of the home, which have been sensitively adapted to suit the needs of service users.

What has improved since the last inspection?

Staffing levels ensure sufficient staff are provided to meet service users needs. Final arrangements are taking place for the appointment of a Manager which when appointed will enhance management structure and care delivered to service users.

What the care home could do better:

Several requirements and one recommendation have been made with regards to developing service users assessments, plans of care and risk assessments to enhance quality of care delivered. To demonstrate choices offered for all meals. To update the complaints procedure to ensure service users are fullyinformed. Further protect service users by providing evidence of staff criminal records bureau checks and providing two staff signatures for transactions of service user finances.

CARE HOMES FOR OLDER PEOPLE Winthorpe Hall Care Home Gainsborough Road Winthorpe Newark NG24 2NR Lead Inspector Karmon Hawley Unannounced 20/7/05 10.00am 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. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Winthorpe Hall Care Home Address Gainsborough Road Winthorpe Newark 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) 01636 701826 01636 701234 Mr R C Pountney Mrs S J Sharp CRH 34 Category(ies) of 34 OP registration, with number of places Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One Named Service user may be within category TI Date of last inspection 21st March 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 extensive grounds a few miles outside 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. There are several main seating areas on the middle floor and smaller more intimate areas on the ground floor. The building and grounds are wheelchair accessible. Service users rooms are maintained at a good standard and some offer ensuite facilities. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Three service users care files, four staff personnel files and other related records with regards to care and the environment were observed. Two staff members and four service users were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Several requirements and one recommendation have been made with regards to developing service users assessments, plans of care and risk assessments to enhance quality of care delivered. To demonstrate choices offered for all meals. To update the complaints procedure to ensure service users are fully Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 6 informed. Further protect service users by providing evidence of staff criminal records bureau checks and providing two staff signatures for transactions of service user finances. 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 C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 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 Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 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 Although staff are currently aware of and meet service user needs, appropriate documentary evidence is not in place to support this, which may adversely affect care received. EVIDENCE: The provider carries out preadmission assessments in the community prior to service users being admitted to the home, however the assessment observed did not cover all the requirements of the standard. Service users spoken with expressed they were happy with care received and their needs were met. Service users observed were relaxed and comfortable with staff and staff demonstrated a good caring rapport with service users. There was evidence of specialist services being liaised with and equipment and aids available within the home. Staff when spoken with were able to discuss care values and principles and the care offered to service users. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 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) 7,8 Whilst service users can be assured their health care needs will be met, care plans are not sufficiently detailed for staff to use as a working tool thus personal care may be compromised. Service users are at a degree of risk due to the lack of the identified risk assessment. EVIDENCE: A computerised care planning system is in use with copies printed as required; additional records of basic information on service users supports this. Care plans examined demonstrated that assessments with regards to pressure areas had taken place. The plan of care was based upon the activities of daily living, however information available was brief and did not fully outline needs and how these would be met. Risk assessments in use identified individual risks however the risk of entrapment for the use of bedrails was not highlighted. There was evidence of monthly reviews taking place and care plans updated as required. Daily records were kept, significant events were noted but information was brief. Staff were able to discuss how they access information with regards to plans of care. There was evidence of specialist services being accessed such as the district nurse and optician and equipment and aids available. There was evidence of service users receiving national health entitlements. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 10 Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 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) 12,14 Service users are enabled to have choice and control over their lives and live a lifestyle that matches their expectations; however further consideration to choice of food is required to enhance this. EVIDENCE: The routine within the home is said to be as flexible as possible, one service user was able to confirm that she is able to get up and retire when she wishes. Service users can choose where they spend the day and were observed to be in various settings. Two care staff assist with activities which include musical movement, sing a longs, games and video afternoons, all but one service user spoken with substantiated this. There was evidence that arrangements are in place for a summer fete to take place in the near future. A specific choice is not offered at the main meal time, the proprietor stated that likes and dislikes are observed and alternatives given as required, however one service user expressed no alternatives were offered and she just left food she did not like. The menu is currently being redevised, this was observed. Service users spoken with expressed they are happy with care received and life within the home. Visitors may be received in private and were observed to do so. Service users may bring in personal possessions to personalise rooms. The local reverend and priest visit the home on occasion. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 12 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 Whilst complaints are taken seriously and acted upon promptly, the policy requires updating to ensure service users and relatives are fully informed. EVIDENCE: No complaints have been received, if they do occur the proprietor stated they are dealt with promptly. The complaints policy is on display, however this is out of date and there is no time scale stated for which complaints will be dealt within. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 13 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 Service users live in a safe and well-maintained environment. EVIDENCE: The proprietor maintains the environment and carries out repairs as required. There is a gardener employed who tends to the grounds. Both the internal and external environment is well kept. There is an ongoing redecoration and improvement system in place. There were no requirements set at the last fire officer visit and work is currently ongoing to achieve requirements set by the environment health officer. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 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 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 There are adequate staff employed to ensure service users needs can be met. Whilst care is taken with regards to recruitment and selection additional measures are required to further protect service users. EVIDENCE: There are currently three staff member employed who are awaiting criminal record bureau clearance, these are long-term staff and applications are currently being processed. Advice was given with regards to Protection of Vulnerable Adult checks with regards to new staff to aid employment and recruitment. No criminal records checks or reference numbers are kept on the premises. Within staff personnel files observed relevant records were available. Adequate staffing levels were observed to be in place for the current occupancy of the home, skill mix is taken into account when planning the duty rota. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 15 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) 33,35 The home is run in the best interest of service users. Service users personal finances are safeguarded, however further consideration is required to ensure they are fully protected. EVIDENCE: The proprietors are currently undertaking recruitment for a home manager and a second interview is arranged for the near future. Quality assurance questionnaires are sent to service users and relatives annually, these cover aspects such as the quality of care; results are collated and an action plan devised if required to improve the service. An annual developmental programme is in place. Personal allowances are kept separately in a lockable facility. There were records of transactions and receipt available, however there were no staff signatures for transactions that had taken place. Service users if able sign for money withdrawn. Three accounts were checked and were correct. There was evidence of audits taking place. The proprietor is not appointee for any service Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 16 user. If able service users hold monies on their selves, lockable facilities are available on request. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 17 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 1 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x 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 Standard No 16 17 18 Score 1 x x x x 3 x 1 x x x Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 18 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 OP3 Regulation 14(1) Requirement The preadmission assessment must be sufficiently thorough to ensure that service users needs can be met within the category of registration. This is an outstanding requirement and must be addressed to avoid enforcement action. Care plans based on a thorough assessment must be in place for all service users and they must be sufficiently detailed for staff to use as a working tool. This is an outstanding requirement and must be addressed to avoid enforcement action. The responsible indivdual is required to ensure appropriate risk assessments are in place for the safe use of bed rails. The registered person is required to demonstrate that choice is offered at all meal times. The registered person is required to demonstrate complaints will be acted upon within 28 days and the complaints procedure shall include the name of the Commission for Social Care Inspection. The registered person is required Timescale for action Immediate 2. OP7 15(1) Immediate 3. OP7 13(4c) 14th August 2005 20th August 2005 20th August 2005 4. 5. OP12 OP16 16(i) 22(4,7a) 6. OP27 4 (b,i) 14th August Page 19 Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Schedule 2 to provide evidence that all staff have criminal records bureau checks in place. A record of registered reference numbers are to be available for inspection. 2005 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 OP35 Good Practice Recommendations Two staff members sign for all transactions of service users personal finances. Winthorpe Hall Care Home C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Edgeley House 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 C03 C53 S24670 Winthorpe hall V240817 200705 Stage 4.doc Version 1.40 Page 21 - 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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