Inspection on 25/04/05 for Wray Common Nursing Home

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Wray Common Nursing Home 08/06/06

Wray Common Nursing Home 27/09/05

Wray Common Nursing Home 22/09/04

Wray Common Nursing Home 19/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Wray Common Nursing Home Wray Common Road Reigate Surrey RH2 0ND Lead Inspector Sandra Holland Unannounced 25 April 2005 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. Wray Common Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Wray Common Nursing Home Address Wray Common Road Reigate Surrey RH2 0ND 01737 242647 01737 240266 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) Dovestone Estates Limited Wray Common Road, Reigate, Surrey, RH2 0ND To be confirmed Care Home (CRH) 51 Category(ies) of Dementia - over 65 years of age (DE(E)), 10 registration, with number of places Old age, not falling within any other category (OP), 51 Wray Common Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 5 service users may be admitted on a day care basis 8am-8pm only and these service users must be included as part of the total number of 49 2. 3. Up to 10 beds may be used for older people who suffer from dementia Services users may be admitted from the age of 60 years 4. Up to three (3) beds may be used for service users with a terminal illness (TI). Date of last inspection 22 September 2004 Brief Description of the Service: Wray Common Nursing Home is situated in a quiet residential area of Reigate. The home provides care for up to 51 service users and accommodation is offered in single or shared bedrooms. There is plenty of communal space in the three lounge/dining areas. There are two gardens, one to the side of the property, overlooked and accessed from one of the lounges and a central courtyard garden, which is overlooked by some bedrooms. The home can provide respite care and day care. Wray Common Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006 and took place over seven and a half hours. The inspection was carried out by Mrs. S. Holland, Lead Inspector for the service and Mrs. M, Williamson, Regulation Inspector. Mr. S. Segal and Mr. H. Segal, Registered Providers and Mrs. P. Fyfe, Manager(matron) were present representing the service. A full tour of the premises was undertaken and 21 service users and 13 members of staff were spoken to. A number of records and documents were examined, including care plans, staff personnel files, medication administration records and policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Whilst the meals served are appetising and alternative choices are made available, the menu plan drawn up is not displayed or followed, so service users are not able to make choices in advance. As a number of service users Wray Common Nursing Home Version 1.10 Page 6 require assistance at mealtimes, more staff need to be made available so that service users do not have to wait. The recruitment and vetting practices and the procedures for the storage of hazardous substances in the home must be strengthened to ensure the protection of service users. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wray Common Nursing Home Version 1.10 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 Wray Common Nursing Home Version 1.10 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) 2, 3 and 5. Service users are provided with contracts/statement of terms and conditions. A needs assessment is carried out prior to service users moving into the home and prospective service users or their representatives are welcomed to visit the home to assess its suitability. EVIDENCE: Contracts seen provide many details about the conditions of residence at the home and are signed by the service user, but it was noted that the room to be occupied and the weekly/monthly amount to be charged were not specified. The manager stated that she carries out a needs assessment of each prospective service user, using the Surrey format, to ensure that identified needs can be met by the home. This was confirmed by the assessments seen in care plans and by a service user’s relative. The service user’s relative also stated that they had been able to view the home and it’s facilities, prior to moving in. Wray Common Nursing Home Version 1.10 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, 9 and 10. Individual care plans are in place and health-care needs are supported by local health care professionals. Medication administration appears to be carried out appropriately. The privacy and dignity of service users is respected. EVIDENCE: Several care plans were looked at and were seen to be well maintained, up to date and had been reviewed to record changes in individual’s needs. The matron stated that a number of local health care professionals visit the home, including general practitioners (G.P.’s), chiropodist, optician and dentist. A Tissue Viability nurse specialist visits the home to provide guidance and support on the care and treatment of wounds. A district nurse who visited the home during the inspection spoke positively of the care provided. Medication administration record (MAR) sheets and the medication policy were seen, along with the storage of medication. The MAR sheets had been completed and a procedure for monitoring any gaps in recording is in place. Sample signatures of those staff administering medication are held. Medication was seen to be stored appropriately and quantities in stock accurately matched the record. The matron advised that the medication policy Wray Common Nursing Home Version 1.10 Page 10 requires review and updating and that she has started new checking procedures to monitor medication. Staff were observed to treat service users with respect, knocking on bedroom and bathroom doors before entering to preserve their privacy and talking to them in a manner that preserved their dignity. Interaction between staff and service users was seen to be positive and appropriate. Service users spoken to were complimentary about the staff and appreciated their support. Privacy screens are provided in shared bedrooms. Wray Common Nursing Home Version 1.10 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, 13 and 15. Few leisure or social activities are available, although service user’s visitors are welcomed and can use the lounges or service user’s bedrooms to meet. Meals are freshly cooked but service users do not know in advance what will be on the menu. EVIDENCE: From the tour of the home and discussions with service users, it was evident that service users lack stimulation and active involvement in a planned programme of activities. Photographs of a recent Easter hat event were seen and the hairdresser was seen attending to a group of service users but little other organised activity was observed. The matron advised that an activities coordinator has been recruited to work three days each week and will start work next month. Service user’s visitors were seen to be made welcome and this was confirmed by visitors who were spoken to and who gave positive feedback about the care provided. A small kitchen is provided on the upper floor of the home for service users or their visitors to make snacks and drinks, but staff stated it is rarely used. Although meals are cooked in the home and looked appetising, there is little evidence of consultation with service users about their preferences and some Wray Common Nursing Home Version 1.10 Page 12 service users stated they disliked the meal that was being served. Others stated they enjoyed the meals and one service user requested alternative food, which was provided. As a menu was not displayed, service users were not able to make a choice until the meal was served to them. A menu plan has been drawn up and was seen but was not followed. It was stated that each chef decides what to cook on a daily basis, with the available ingredients and what is served is recorded in the kitchen diary. In one dining room a number of service users were seen in need of assistance to eat their meal, but only one member of staff was available Wray Common Nursing Home Version 1.10 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 standard(s) These standards not assessed at this inspection. EVIDENCE: Not applicable. Wray Common Nursing Home Version 1.10 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 23, 24, 25 and 26. The standard of the environment in the home is good, providing service users with an attractive and homely place to live. Adaptations to meet the needs of service users are available and bedrooms are personalised. EVIDENCE: All areas of the home were seen, apart from the private offices. The standard of decoration within the home was observed to vary, from the high standard of the newly built wing to an acceptable standard in the older areas of the building. Decorating was in progress in a bedroom corridor at the time of the inspection. Most bedrooms are for single use, all with fitted washbasin and some with en-suite toilets and basins and most are personalised with ornaments, pictures and photographs. Bathrooms and toilets are located close to service user bedrooms and have a variety of adaptations fitted, including grab rails, hoists and specialist baths. All areas of the home were clean and freshly aired. Wray Common Nursing Home Version 1.10 Page 15 Wray Common Nursing Home Version 1.10 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 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, 28 and 29. A team of staff are employed to meet the needs of the service users. Since the last inspection the standard of recruitment and vetting practices has declined, with appropriate checks not being carried out and potentially leaving service users at risk. EVIDENCE: The staff group includes nurses, care assistants and domestic, laundry and kitchen assistants under the leadership of the matron and deputy matron. A number of staff members were spoken to and some staff stated they had worked at the home for a number of years, whilst others confirmed that they had joined more recently. The registered providers advised that they and an administrator carry out financial and business associated roles. Staff personnel files were seen. These did not contain all the documentation required to protect service users, such as Criminal Record Bureau (CRB) clearances and nurse’s personal identification number (PIN) checks, although a PIN check was carried out during the inspection. Identification and medical checks were not recorded in all cases. Wray Common Nursing Home Version 1.10 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 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) 31, 36, and 38. The care aspects of the home are managed by a manager (matron) and business management is overseen by the registered providers, who are involved on a day to day basis. The health, safety and welfare of service users and staff are not being safeguarded. EVIDENCE: The manager was appointed six months ago and she demonstrated a good understanding of the areas in which the home needs to improve and is prioritising the actions required. She stated that she has been assessing and reviewing the care provided in order to identify areas for improvement and has already revised some policies and procedures. New methods of record keeping, such as formal supervision of staff have been introduced. The manager advised that regular supervision of staff is now being planned. The manager has applied for registration with the Commission for Social Care Inspection (CSCI). Wray Common Nursing Home Version 1.10 Page 18 During the inspection a number of potential or actual hazards to the health and welfare of service users and staff were noted: • Cleaning materials were observed in a service users’ bathroom and were seen left unattended in the corridor. • Storage facilities for cleaning materials were not lockable. • Radiator covers were not attached to the wall. • Food in the kitchen fridge was not labelled, dated or properly covered. This was discussed with the manager and advised accordingly. Wray Common Nursing Home Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x 2 x 1 Wray Common Nursing Home Version 1.10 Page 20 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 2 Regulation 5A Requirement Service users must be provided with a statement specifying the fees payable for accommodation, including the provision of food, nursing and personal care, and, except where a single fee is payable for these services, the services to which each fee relates. The statement must also specify the method of payment of fees and the person(s) by whom the fee is payable. This statement must be provided to a service user not later than the day on which he/she becomes a service user. Having regard to the size of the care home and the number and needs of the service users, a programme of activities must be drawn up, in consultation with service users. A person must not be employed at the care home unless all the records and documentation required in Schedule 2 of The Care Homes Regulations 2001(as amended) have been obtained and are held in the care home. All parts of the home to which service users have access must Version 1.10 Timescale for action 24th June 2005 2. 12 16 (2)(n) 24th June 2005 3. 29 19 Immediate from 25th April 2005 4. 36 13 (4) (a) Immediate from 25th Page 21 Wray Common Nursing Home 5. 36 13 (4) (c) be kept, so far as is reasonably practicable, free from hazards to their safety. Unnecessary risks to the health or safety of service users must be identified and so far as possible, eliminated. All food items must be appropriately stored, labelled and dated. April 2005 Immediate from 25th April 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 15 Good Practice Recommendations It is recommended that service users are consulted about the menu offered, that choices of meal are notified in advance and that the menu plan is displayed and followed. It is also recommended that provision is made to ensure that service users meals are maintained at the correct serving temperature, whilst they await assistance from staff at mealtimes. It is recommended that provision is made for allocated management time and office space to enable the manager to fulfil her duties. Care staff should receive formal supervision at least six times a year. 2. 3. 31 36 Wray Common Nursing Home Version 1.10 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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