CARE HOMES FOR OLDER PEOPLE
Wold Haven 36 Burnby Lane Pocklington East Yorkshire YO42 2QD Lead Inspector
Anne Prankitt Unannounced Inspection 21st March 2006 10:20 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.V285975.R01.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. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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) 01482 887700 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 Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th December 2005 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. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection lasted for four and a half hours. Three hours preparation took place prior to the inspection. Debra Parker was the duty Senior Care Officer. She assisted during the course of the inspection. The registered manager, Barbara Kavanagh, was also available. She was provided with feedback at the close. As all but one of the key standards had been assessed at the last inspection, the purpose of this inspection was to look at quality assurance systems, follow up any requirements made at the last inspection, look at some care plans and speak with service users, staff and visitors. In addition to this, a tour of the communal areas was undertaken, and a random sample of bedroom areas were seen. What the service does well:
The home is situated near to the centre of Pocklington. Residents who are able to can access the local shops and market. There is a choice of communal areas where residents may choose to sit which gives the home a homely feel. The residents stated that they liked living at the home, and that they were happy there. They said that the staff are kind, and that they understand their care needs. Activities are organised by staff Monday to Friday, to assist in meeting the social and recreational needs of residents who wish to join in. Visitors were very complimentary about the home. They stated that they were welcomed at any time, that the care was good, and that their relative was settled. Each resident has a care plan which is kept up to date by staff so that it is clear what help the resident needs, and where they are at risk. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 6 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. Wold Haven DS0000035351.V285975.R01.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 Wold Haven DS0000035351.V285975.R01.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): EVIDENCE: None of the standards were assessed at this inspection Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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): 7 and 8 The care plans contain sufficient information to help staff understand the needs of service users and how they are to be met, and assist in ensuring that advice is sought from other professionals where required. EVIDENCE: Care plans contained good information from which care could be understood and delivered. Care staff use the plans as working documents, and discussion is had between keyworkers and senior care officers about their review during supervision sessions. Care staff were knowledgeable about the needs of service users. Risk is assessed by senior staff members, and this is also reviewed on a regular basis. There were no risk assessments in place for the use of bed rails. It was agreed that bed rails would be checked before next being used, and that written risk assessments would be completed within two weeks, to include details that they will be checked on a regular basis. Nursing care is provided by the visiting district nurse, and the staff seek the advice of outside professionals such as the dietician, Community Psychiatric Nurse and stroke nurse where they are concerned about meeting the needs of service users in order that advice can be sought. Service users are assessed as
Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 10 necessary with regard to their continence needs, and continence aids provided accordingly. Equipment to reduce the risk from pressure sores is secured for service users where required. Service users spoken with were very satisfied with the care that they receive at the home, and of the attention paid to them by staff. Comments included: ‘It is very nice here’, ‘The care is good’, ‘The staff come if I call’, ‘The manager comes to see us’. ‘I can get up and go to bed when I want’. Visitors were also extremely complimentary about the care that is provided. Comments included ‘I am delighted with the care’, ‘The staff are marvellous. They have time to act as keyworkers’. ‘The bell rings and it is answered’. ‘We know who our keyworker is – nothing is too much trouble.’ ‘It is my relative’s home’. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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): EVIDENCE: None of the standards were assessed at this inspection Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of the standards were assessed at this inspection. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of the standards were assessed at this inspection. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Staff are appropriately vetted prior to deployment to ensure that service users are safeguarded from unnecessary risk. EVIDENCE: The staff files of three recent starters were inspected. In each case, there were two written references and a Criminal Records Bureau check returned prior to each of the staff members being deployed. On the day of the inspection, a new staff member was being supervised by another member of staff. Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 There are systems in place for consultation with service users, whose views are considered as part of the quality review. EVIDENCE: The home currently holds the QDS award levels 1 and 2. This includes surveys about personal care, staff development and the environment. The local authority are currently meeting to further improve this in order that the views of stakeholders can be sought and used as part of the quality assurance system. This will soon be introduced. Within the home, residents’ meetings are held on a regular basis. Issues brought up are looked into, and feedback provided at the next meeting. In addition to this, care plans are audited on a regular basis. On the day of the inspection, visitors were seen to come and go, and the office appeared to adopt an ‘open door’ policy. A number of commendation cards were seen which expressed satisfaction with the service. The registered manager is considering the possibility of the reintroduction of relative meetings as part of the formal process of quality assurance.
Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 16 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 X X 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 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 17 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 2 Standard OP7 OP7 Regulation 13 13,15 Requirement All bed rails must be checked before next being used. Written risk assessments must be developed within two weeks for all service users who have bed rails fitted to their beds. The assessment must include written evidence that the bed rails are checked on a regular basis to confirm that they are safe and fit for use. Timescale for action 21/03/06 04/04/06 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.V285975.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Wold Haven DS0000035351.V285975.R01.S.doc Version 5.1 Page 19 - 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!
