Inspection on 10/04/06 for Witnesham Nursing Home

This inspection was carried out on 10th April 2006.

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 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

Witnesham Nursing Home 20/04/07

Witnesham Nursing Home 07/12/05

Witnesham Nursing Home 12/05/05

Witnesham Nursing Home 07/03/05

Witnesham Nursing Home 22/06/04

Witnesham Nursing Home 05/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Witnesham Nursing Home Wearholme, The Street Witnesham Ipswich Suffolk IP6 9HG Lead Inspector Jan Davies Unannounced Inspection 10th April 2006 11:00 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 Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Witnesham Nursing Home Address Wearholme, The Street Witnesham Ipswich Suffolk IP6 9HG 01473 785828 01473 785779 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) Dibcan Limited Mrs Carole Ann Glegg Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Witnesham Nursing home is situated in the village of Witnesham on the northern outskirts of Ipswich. The home is registered as a care home with nursing for a maximum of 30 service users in the category of older people. The home has 2 lounges, a dining room with a small private sitting area adjoining and all bedrooms are adequately furnished and decorated with each service user being able to choose the colour scheme of their own room. Service users are encouraged to bring in personal possessions and small items of furniture for the rooms. Most of the rooms are of single occupancy. There is a nurse call system in place that is accessible to service users in all bedrooms, bathrooms and communal areas. A shaft lift allows access to the first floor and the home and its gardens are accessible to wheelchair users. The manager, referred to as ‘matron’, leads a team of care staff who are trained to meet the needs of the service user. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a normal weekday in April between the hours of 11am and 5pm. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. There were a number of residents in the home at the time who contributed to the inspection and their views and comments have been incorporated into the writing of this report. A tour of the premises was made and a number of records were examined including those relating to the care of residents, staff records and a selection of policies and procedures. Time was spent talking with a number of residents, the matron/manager and the staff members from 2 shifts. The inspector inspected care plans, staff training records, medication records, risk assessments, residents’ personal files, observed a meal-time and looked at complaints information and examined adult protection information. There were a number of relatives or other visitors visiting at the time of the inspection who were observed to be made welcome and encouraged to spend appropriate social time with residents. What the service does well: Residents are provided with a comfortable and homely environment that is clean. Residents spoken with were complimentary about the home describing the food as ‘very good with plenty of choice’ and the general level of care given to them as ‘kind and helpful.’ A risk management framework is in place for the promotion of independence for residents and residents’ preferences and choices are documented in their care plans. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 6 The home has good arrangements for admission and supporting service users with care planning. Personal support was given and health care needs promoted within the home and help given to access the community-based facilities for this. Arrangements were in place for meeting the health and personal care needs of service users. The day-to-day operation of the home appeared sound with written information to demonstrate this. What has improved since the last inspection? 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. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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 Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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): 1,3,4,5 The admission procedure is clear and there is a proper assessment in place for all prospective residents prior to people moving into the home. Care needs are being properly assessed and catered for. EVIDENCE: Copies of assessments carried out at the time of referral were held on file and had been supported by further skills assessments the manager of the home had carried out. From a number of care plans viewed and admission details it was demonstrated that appropriate pre inspection visits had been arranged. The inspector checked that no changes had been made to this arrangement. The admission procedure was appropriate to guide staff on the actions to be taken to ensure that new residents needs were properly assessed and planned for. Relevant information was provided in service user plans about any specialist arrangements for specific medical conditions, such as diabetes, tissue viability and infection control advice. This included appropriate clinical information, and information regarding diet and healthcare daily plans. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 9 These services and facilities in place were stated as being catered for in the home’s statement of purpose. Some residents spoken to were able to provide significant information about their care needs and the inspector was able to check that this was confirmed in their care plans. This also included asking the residents and relatives if they had had all the information they needed to make an informed choice about this home. All were very positive about why they had chosen this particular home. The inspector looked at individual records of care and, in five cases all records referring to those residents were looked at. These contained full assessment information. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 10 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): 7,8,9,10,11 There are arrangements in place to ensure that the health care needs of residents are identified and met. Residents do not always have their social needs fully documented in care plans. Care plans do not include information about restrictions to privacy or dignity. EVIDENCE: The inspector examined the care plans and care records for a number of residents. These documents contained requisite personal information about service users, life histories, personal care preferences and records, other preferences such as diet and daily routines, detailed night care arrangements, leisure preferences and care plans based on a commonly adopted care planning format. The care plans were reviewed by key-workers on a monthly basis and full reviews were conducted annually. Minutes of these review meetings were present in the care records. Each service user’s care records contained a manual handling risk assessment, a nutritional assessment, weight monitoring chart and a continence care assessment. These risk assessments were reviewed on a monthly basis. GP visits were recorded and visits from other healthcare professionals were also kept. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 11 Residents talked to the inspector about what they would personally like to achieve in terms of their overall care planning referring to wanting to work towards more mobility or wanting to get out into the garden in better weather ‘under my own steam.’ These aims should form the basis of care planning and be developed to provide a more holistic approach to care planning. Care plans would benefit from including more information about the residents social care to reflect that individual objectives were worked towards and met. Several residents were observed to wear food protectors at meal times. This should be referred to in their care plan and their agreement obtained. Some residents did not have net curtains for privacy. It should be recorded in their care plan that this is their choice. Residents sharing rooms should have their consent to this recorded in their care plans and this situation regularly reviewed. The home was successfully using a monitored dosage system for the medication. Receipt, disposal, recording and administration practices of medication were checked. These were discussed with the manager and were considered to be acceptable and safe on the day of inspection. No shortfalls were identified or unexplained gaps noted on the medication administration records. Clear risk assessments were in place for service users who were able to self-medicate. Most, but not all, care plans contained information about residents’ preferences and arrangements to be in place for resuscitation and dying and specific arrangements for residents at the end of their lives. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 12 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): 12,13,14,15 Social activities are well-managed, creative and provided daily variation and interest for people living in the home. Relatives and friends are made welcome. Menus provide good nutrition. EVIDENCE: An activities log was kept at the home. This was completed and kept up to date by staff. Entries included a buffet tea, videos, classic concert tapes, a group crossword, singing hymns, playing bingo, doing jigsaws and playing other games. Service users confirmed that entertainments and activities took place within the home and that they enjoyed these. The inspector was able to view this and saw that staff were skilled at providing activity sessions that residents enjoyed. A number of people living in the home were spoken to and everyone who commented on the food said they enjoyed it and that meals were well cooked. On the day of the inspection there was a choice of main meal of the day, vegetable stew and liver and bacon, and it was noted that residents were being asked what they preferred before food was put in front of them. Vegetarian and individual preferences were taken into account and appropriate records of meals were being kept. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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): 16,18 The home has an appropriate complaints policy but not all staff are aware of the complaints’ procedure for the home. Staff awareness about the home’s adult protection policy is varied and residents cannot expect to be fully protected from abuse until all staff are aware of the correct procedure to follow. EVIDENCE: Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 14 There was a written complaints procedure that was well presented for the resident group. This included a section where the action taken to investigate and/or resolve the complaint can be written. The procedure had been updated to include information regarding how to contact the CSCI. There was a record kept of all complaints. Since the last announced inspection a complaint related to the standard of care of residents and competence of staff had been received to the CSCI. This had been fully investigated with appropriate and time-scaled requirements and recommendations made to implement training for staff and include more robust and detailed care planning. The home has since complied. However at the time of the inspection not all staff were aware of the home’s complaints’ and prevention from abuse policies but all said they would seek advice from the matron. While this is appropriate when matron is on duty there are times when staff would not have direct access to her to consult and all staff must be aware of what to do. The home had a policy for adult protection and protocols for this. Not all staff members spoken with were fully conversant with the home’s whistle-blowing procedure nor able to identify who to contact if an allegation were to be made about senior management. The home would benefit from having a copy of the local Suffolk County Council adult protection and whistle blowing policy explaining the responsibilities incumbent upon staff to refer genuine concerns about issues of poor practice or abuse to management, as well as the legal protection afforded to them under the Public Interest Disclosure Act 1998 in these cases. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,24,25,26 Service users were living in a safe, well-maintained and clean environment. EVIDENCE: The home was designed in line with National Minimum Standards and was being properly maintained. At the time of the inspection all areas visited by the inspector were clean and hygienic. Well- tended and pleasant gardens were available for the use of service users with wheelchair ramp access. The home was clean and odour free at the time of inspection. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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): 27,28,29,30 The procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. The deployment and number of staff available at all times of day was sufficient at the time of the inspection to meet the assessed needs of residents. EVIDENCE: Inspection of staffing rosters and discussion with staff, relatives and residents indicated that the staffing levels at the home were currently appropriate. Sufficient care staff were on duty at different times during the day and in the mornings additional care staff were on duty. The inspector checked any personnel files for staff recently recruited to the home. These files contained all of the documentation required by Regulation, including two written references, Criminal Records Bureau (CRB) Disclosure checks and proof of identification. During the inspection six staff were interviewed and their training records examined. Training records were up to date, included appropriate training and addressed the training needs of staff with corresponding appraisal. Residents said that the staff at the home were kind and caring and were never too busy to spend individual time with them to support, encourage and reassure at times when this was needed. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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): 31,32,33,34,35,38 There is appropriate leadership providing staff with guidance and direction to ensure that residents receive consistent good care. Health, safety and welfare of people using this service is being promoted. EVIDENCE: The combination of the manager’s experience, qualifications and positive attitude in evidence during the inspection and the level of care in evidence at the home indicated that the manager was suitably qualified and competent to manage the home. There was a pleasant atmosphere at the home on the day of the inspection. The matron and the staff were open and helpful and residents were complimentary when referring to the care they received. Residents stated that they would have no difficulty in raising concerns with the matron, who was very approachable and that their needs are prioritised. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 18 Evidence recorded from more than one source indicated that there were suitable financial procedures in place and that the home was financially viable including a current, up to date certificate demonstrating appropriate Employers Liability Insurance for the business on display outside the main office. Other forms of insurance, such as buildings and contents were not assessed on this occasion. Residents’ files were sampled and reflected that there are appropriate arrangements made by residents and their families or appointed representatives to safeguard their financial interests. The home’s staff members are not appointees for residents’ money and are not authorised in this capacity. This arrangement reflects good practice and maximises financial security for all residents. The home’s policy and procedures file reflects that staff have the appropriate information about this available to them and induction training information shows that this topic is covered when staff begin working in the home. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 19 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x 3 x 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 x x 3 Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 20 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 OP18 Regulation 13 (2) Requirement Clear procedural guidance must be available for staff to follow in the event of an allegation, or suspicion, of abuse. Timescale for action 07/05/06 2. 2. OP16 OP18 13 13 (6) All staff must have an ‘overview’ 07/05/06 of the complaints’ procedure for the home. The present POVA policy must be 31/05/06 updated to reflect county guidelines. Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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 OP7 Good Practice Recommendations Care plans and daily records should show evidence of a holistic approach to care and include psychological needs and moods of the resident. There should be reference in care plans that residents’ agreement to wearing food protectors has been obtained. It should be recorded in their care plan that resident’s choose to not have net curtains. Residents sharing rooms should have their consent to this recorded in their care plans and this situation regularly reviewed. Care plans contained information about residents’ preferences and arrangements to be in place for resuscitation and dying and specific arrangements for residents at the end of their lives. All ancillary staff should have POVA training. 2. OP10 3. OP11 4. OP18 Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Witnesham Nursing Home DS0000024530.V287411.R02.S.doc Version 5.1 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. 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. 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