Inspection on 13/12/06 for Wold Haven

This inspection was carried out on 13th December 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wold Haven 21/03/06

Wold Haven 05/12/05

Wold Haven 14/02/05

Wold Haven 07/10/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Wold Haven 36 Burnby Lane Pocklington East Yorkshire YO42 2QD Lead Inspector Sarah Sadler Unannounced Inspection 13th December 2006 09:00 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 Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wold Haven Address 36 Burnby Lane Pocklington East Yorkshire YO42 2QD 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) 01759 303085 01759 307322 East Riding of Yorkshire Council Barbara Kavanagh Care Home 37 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (37), of places Physical disability (1) Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category (PD) refers to a named service user only. Date of last inspection 21st March 2006 Brief Description of the Service: Wold Haven is a single storey building located approximately half a mile from the town centre of Pocklington and service users can access the local shops, public houses and cafes. The home is owned by the local authority and is registered for 37 older people (male or female), over the age of 65 years of age, 6 of whom may have a dementia. All rooms are for single occupation. There is a garden and patio area. The registered manager confirmed in the pre-inspection material that the weekly fee for residing in the home is £447.60. There are additional varying fees for hairdressing, chiropody, newspapers and toiletries. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was undertaken as part of the routine programme of inspections. It commenced at 09.00 and was completed at 16.00 on 12 December 2006, with a previous one-day’s preparation. The registered manager and staff team, although busy with Christmas preparations, assisted the inspector throughout the day. Several service users and staff were spoken to and one visiting relative, although no health professionals were available for interview. A tour of the premises was undertaken and residents’ files and other records were examined. This included pre-inspection material provided by the manager. Service user surveys were returned from six service users; some had been assisted by their relatives in the completion of these. The surveys all reflected positive comments about life in the home and raised no negative issues. One professional survey was received; again, no issues about the care provided in the home were raised. What the service does well: The home is managed in a manner that is service user focussed. It concentrates on the needs, wishes and views of the people who use the service. The home is clean and comfortable. Staff and service users have good relationships. Comments made by service users included “the staff are so helpful” and “the carers are exceptional”. Service users are able to access the primary health care team and other health professionals ensuring that their health care needs are met. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 6 Visitors are encouraged and made welcome. They are able to join their relative in activities. This helps service users maintain contact with family and friends. There is a clear complaints procedure and there is evidence that complaints would be taken seriously. This promotes openness and transparency, which encourages service users and others to say if they are not happy with any aspect of the service 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. The summary of this inspection report can be made available in other formats on request. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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 Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed prior to admission to make sure that Wold Haven can deliver the care needed. EVIDENCE: The four service user files assessed all included a copy of an assessment undertaken by the Local Authority prior to the person moving into the home. This assessment details the person’s individual needs and the support required. The information has then been used by the home in completing a plan of care. This ensures that the staff team in the home are aware of the individual’s strengths and needs, and that these needs can be met. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 9 The registered manager confirmed that the home does not provide intermediate care. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and personal care needs are met. EVIDENCE: Each service user has an individual plan of care that details the support required from the staff in order for those needs to be met. The plan is comprehensive and covers, for example, peoples’ strengths and needs, including religious needs and health needs. The manager and staff team have regularly reviewed the plan to ensure that it reflects the persons up to date needs and continues to assist with these being met. Peoples’ health and personal care needs are clearly identified in the plan of care, ensuring that staff are aware of these and the support that is required in Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 11 ensuring that they are met. Records are kept of any visits to or by health professionals and letters and reports from these professionals are also kept on file. These records allow for an up to date picture to be kept of the individuals needs and assist staff in the meeting of these needs. To help people meet their needs safely, individual risk assessments have been developed. These identify any areas which may cause a risk and the necessary actions staff need to undertake to ensure that, whilst peoples needs are met, risks are reduced. Not all of the people who use bed rails to support them have risk assessments in place and the registered manager confirmed on the day of the visit that this is to be addressed. Medication is well managed within the home. One service user’s file included a signed disclaimer stating that they were able to administer their own medication. Other service users are supported by the staff team with their medication needs. Medicines are stored within a locked cupboard and records are kept of all receipt, administration and disposal of medicines. By ensuring accurate records and following the correct procedures people’s medication needs are safely met. Staff were observed to interact both positively and politely with service users. Service users’ appearances reflected their individual personality and, when questioned staff reflected positively on maintaining peoples’ privacy and dignity, with answers including, ‘ensuring peoples curtains were closed and that people were covered whilst personal care was being provided’, an ‘letting people know what you were going to do next so that people were not surprised by this’. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive a service that is in line with their expectations and preferences within the care home setting. EVIDENCE: People are enabled to make different choices in their everyday lives. Service users were observed to chose what they wished to do either to join in activities, mix with others or to spend time alone in their room. People are offered choices in their lives, which, includes the food they eat. Daily diary notes reflect the choices that people make, for example, enjoyed bingo, out for lunch with granddaughter and time in room. On the day of the visit a large group of service users attended a word game session. The registered manager confirmed that an in house activity occurs every day Monday to Friday. One relative commented in a survey “ My mother loves all the activities especially a sing a long! Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 13 Service users are supported to maintain family relationships. Records reflect that people receive visitors, as they would wish. Some visitors were present at the time of the visit and joined in with their relative in the activity in the main lounge area. One visitor confirmed that they could visit at anytime. Another service users notes recorded that they had been supported to telephone their daughter. Service users continue to be able to exercise some choices and control in their lives. Where possible, people are able to continue to manage their own finances. There are various information leaflets available for agencies such as advocacy and people are able to personalise their rooms to their own tastes. The inspector had lunch with service users. It was nicely presented, served hot and tasty. Dining room tables were set properly with tablecloths, appropriate cutlery and condiments. People were offered a variety of food and said that this is the case each day, and that the standard of this was good. People were well supported by the staff team and ate their meal in a relaxed atmosphere. Staff were aware of individuals needs and the support required with the eating of their meals. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to ensure that concerns can be raised and dealt with effectively, whilst service users are protected from harm. EVIDENCE: The Local Authority’s complaints procedure is available within the home; this includes the contact details of the CSCI. The manager confirmed that there have been no complaints since the last inspection. The relative interviewed confirmed that they could raise any issues with the staff on duty. There is a copy of the Local Authority’s policy ‘The Protection of Vulnerable Adults’, which provides the staff with the correct procedures to follow should an allegation of abuse occur. One member of staff confirmed that they had a good knowledge of protecting people, which included the correct procedure for reporting any allegation of harm or abuse. In addition the home have another policy for the handling of allegations of abuse. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, safe and comfortable home. EVIDENCE: The home is clean, fresh and is furnished and decorated to a good standard. The relative commented, “ the cleaners are outstandingly good, they are fantastic, they really do a good job”. There are a number of communal lounges and other smaller sitting areas around the home. This provides service users with a choice of place to sit quietly, meet with family and friends or be actively engaged with other service users. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 16 All of the bedrooms are single rooms. Service users are encouraged to have some of their personal possessions in their bedrooms, this allows people to have familiar things around them and helps promote a sense of individuality and feelings of ownership. There are four bathrooms with assisted bathing facilities. Toilets are placed strategically around the home. Commode facilities are available in bedrooms if needed. Call bells are within reach of service users and were observed to be regularly used and responded to. Aids and adaptations are provided and regularly serviced. The garden areas are well maintained and the courtyards are made attractive with planting and other garden features. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are properly recruited and trained to ensure that service users receive a good standard of care. EVIDENCE: Duty rotas seen by the inspector reflected that staffing levels vary throughout the day to ensure that service users needs are met. Care staffing levels are complimented by a number of catering and domestic staff. The manager detailed a variety of courses in the pre-inspection material that had been undertaken by the staff; this was confirmed in the staff records and by the member of staff on duty at the time of the inspection. The courses included first aid at work, understanding dementia, fire training and the protection of vulnerable adults (POVA). The registered manager confirmed in the pre inspection material that 68 of the staff team are now qualified to National Vocational Qualification (NVQ) level 2 or above. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 18 Being well trained assists the staff team in meeting the needs of the service users to a high standard. Good recruitment procedures are followed and all of the staff have Criminal Record Bureau checks (CRB) and references undertaken on them prior to them commencing working in the home. This was confirmed in the pre-inspection material and was evident in the staff files. These processes assist in ensuring that people are suitable to work within the home. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a manner that promotes the right of service users to enjoy a good quality of life. EVIDENCE: The registered manager has managed the service for some time and over the last year has updated her knowledge. She holds the Registered Managers Award and has undertaken dementia care and physical intervention training. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 20 There is a quality assurance system in place, which takes into account the views of the service users, staff, relatives and other stakeholders, enabling them to be involved in the development of the home. A report is produced from the findings of the quality assurance questionnaires and actions are taken as necessary. There is a system in place for the handling of service users finances. This ensures that records are kept of all income and expenditure with receipts being kept for all expenses. There are up to date health and safety checks undertaken within the home, these include the gas, portable appliance testing and fire systems. Written records are kept of these and other health and safety issues, for example any accidents or incidents. The electrical wiring has been identified as unsatisfactory and in need of replacement; the registered manager confirmed that this has been assessed by the local authority as safe to continue using. The registered person must forward written evidence of this to the CSCI. Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X 3 X X 2 Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13,15 Requirement Written and reviewed risk assessments must be in place for all service users who have bed rails fitted to their beds. Written evidence must be provided to the CSCI that the electrical wiring systems within the home are safe. Timescale for action 30/01/07 2 OP38 13 30/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wold Haven DS0000035351.V308424.R01.S.doc Version 5.2 Page 24 - 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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