Inspection on 27/09/05 for Wray Common Nursing Home

This inspection was carried out on 27th September 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 25/04/05

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 Announced Inspection 27/09/05 10:45 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 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 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. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wray Common Nursing Home Address Wray Common Road Reigate Surrey RH2 0ND 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) 01737 242647 01737 240266 Dovestone Estates Limited Patricia Mary Fyfe Care Home 51 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (51) of places Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 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 Up to three (3) beds may be used for service users with a terminal illness (TI). 25th April 2005 Date of last inspection Brief Description of the Service: Wray Comon 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, day care for up to five people, terminal care for up to three people and care for up to ten people who may have dementia. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. Mrs. Sandra Holland, Lead Inspector for the service, carried the inspection out over six and a half hours. Mrs. Patricia Fyfe, Registered Manager, Mr. Howard Segal and Mr. Stanley Segal, Registered Providers were present, representing the service. A number of records and documents were examined, including, resident contracts, the complaints procedure and record, staff training records and the activities programme. 15 residents, 3 visitors and 12 members of staff were spoken with. CSCI comment cards were issued to the home prior to the inspection, for distribution to residents, relatives and friends, general practitioners, healthcare professionals and care managers. This is to provide an opportunity for all those involved in the home to independently feedback their views on the service provided, to CSCI. It was pleasing to see that the home had distributed these with a covering letter of explanation and a good response was obtained. The majority of responses were positive and complimentary about the standards of care and support provided at Wray Common. Of the residents who responded, it was pleasing to see that the majority of the respondents like living at the home, feel well cared for and feel safe. Some responses from relatives or visitors stated that the writers were unaware of the inspections at the home and unaware that a report is produced. Other responses stated that the writers felt that there were not enough staff at the home or that they were unaware of the complaints procedure. This information was relayed back to the management of the home. The people living at the home prefer to be known as residents and that is the term that will be used throughout the report. What the service does well: The home is well maintained and attractively decorated. It presents as a cheerful place in which to live. Many staff have worked at the home for many years, creating stability and providing residents with continuity of care and support. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 6 The manager continues to prioritise where improvements can be made to the service provided and initiating these. What has improved since the last inspection? What they could do better: Contracts, which state the terms and conditions of residence at the home have not been reviewed and revised. These need to specify the fees payable, what the fees relate to, who is responsible for paying them and how. The home’s complaints policy and procedure needs to be reviewed and revised. Staff have been employed without the documents and records specified in Schedule 2 of The Care Homes Regulations, being obtained. Dementia training for staff needs to be arranged to ensure that the home meets the needs of residents. Allocated management time and office space to enable the manager to fulfil her role have not been provided. Radiator covers in the upstairs lounge/dining room need to be secured to the wall to ensure the safety of residents and staff. (This was specifically identified at the first inspection this year on 25/04/05). Please contact the provider for advice of actions taken in response to this Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 8 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 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 9 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): 2 and 6. The contracts which are supplied to residents, contain some but not all of the required information. EVIDENCE: The provider stated that contracts issued to residents have not been reviewed or revised. A requirement that the contracts at the home be reviewed and revised was made at the last inspection. Those seen did not specify the full fee payable, who was responsible for paying the fee or contributions towards it and how the fee would be paid. The room to be initially occupied was not specified on the contract. This requirement remains unmet. The manager stated that intermediate care is not provided at the home. A requirement has been made. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 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): 11. Residents are cared for sensitively, until the end of life. EVIDENCE: The manager stated that wherever possible, each resident is asked their preferences for care at the end of their life and this is recorded in their care plan. A care plan was seen to have recorded very specific end of life wishes for one resident. The manager advised that this can be a very difficult subject to approach, both for residents and staff, but the need for obtaining this information is clearly understood. It is recommended that where a resident does not wish to discuss this, it be recorded as such in the care plan. The home’s policy for the care of those dying or who have died was seen. The policy was reviewed recently and is to be integrated into a new policy, recently obtained. Whilst no concerns have been raised, it was noted that there have been a high number of deaths at the home this year. The manager advised that the home has developed a reputation locally for the high standard of it’s care of residents who are terminally ill and a number of residents had been admitted specifically Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 11 for end of life care. The home is well supported by the local palliative care nursing team, who were seen in the home on the day of inspection. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 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): 14. Residents are supported to retain control of their lives and make their own choices. EVIDENCE: The manager stated that residents are encouraged to maintain control over their own affairs for as long as they are able. Residents are able to choose how they spend their time and their timescales for getting up and going to bed. The home retains contact details for local advocacy services and these are provided to residents and their families or friends as required, the manager advised. Residents are able to bring their own belongings into the home and the provider advised that this is usually agreed during the admission process. Residents were seen to have personalised their rooms with pictures, photographs, plants and small items of furniture. Residents are encouraged to be involved in the drawing up and reviewing of their care plans, the manager advised, and those seen had been signed by the resident concerned. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 13 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. A complaints procedure is available, but needs to be reviewed. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A complaints policy and procedure is in place and is stored in the office. The policy was marked to show that it had been recently reviewed but a copy of the procedure displayed outside the manager’s office was noted to be out of date. This referred to the previous manager and to the National Care Standards Commission, which no longer exists. The manager stated that a new set of policies and procedures has recently been obtained and that she is in the process of linking the new policies to the old, or replacing, as appropriate. A complaints record book was seen and the last entry was dated ten months previously. A response to the complaint was seen in the manager’s handwriting, although the response had not been signed or dated. From the CSCI comment cards, it was noted that some residents and visitors were not aware of the home’s complaints procedure and it is required that this is made available, in a format suited to the needs of the residents. A copy of the most up-to-date, Surrey Multi-Agency procedure for the Protection of Vulnerable Adults is held in the home. This would be, and has been instigated, in the event of concerns being raised regarding abuse or possible abuse of residents in the home. The manager also advised that the Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 15 home has a “Whistle-blowing” policy and holds a copy of “No Secrets”, a government produced document about the prevention of abuse. The manager stated that staff are introduced to the home’s policies and procedures regarding the protection of residents during their induction to the staff team. Further training about abuse issues is also carried out and records confirming this were seen. Staff spoken to, were aware of their responsibilities in the protection of residents and stated that they would be willing and able to report any concerns they had. A requirement has been made. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 16 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): 20. The communal areas of the home are attractively decorated and well furnished, providing a comfortable environment. EVIDENCE: There are three lounges in the home, which also have dining areas allocated. These are all cheerfully decorated with a selection of pictures on the walls. Furnishings had been selected to co-ordinate with the decorations and carpets and one lounge had recently had new curtains fitted. A range of comfortable armchairs and footrests are provided. The dining tables and chairs were of a modern style, suited for their purpose and are sometimes used for activities such as board games and puzzles. Lighting fittings were well placed to suit the needs of the residents, were of good quality and were domestic in character. Flowers and plants were placed around the home, creating a homely atmosphere. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 17 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 18 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 and 30. Recruitment practices in the home must be more robust. Regular staff training takes place. EVIDENCE: It is of concern that a number of staff have been permitted to work at the home, without a Criminal Records Bureau (CRB) clearance having been obtained in respect of those staff. Additionally, for some qualified nurses employed at the home, no record is held of their Personal Identification Number (PIN) or the expiry date of their PIN is not known. Consequently, these nurses may be working in an unregistered capacity, which must not be permitted. An immediate requirement was made at the last inspection, that persons must not be employed to work at the home, unless the records and documents specified in Schedule 2 had been obtained in respect of those persons. It is unacceptable that this has continued to take place, as it puts the residents at risk. The provider stated that some staff have been unwilling, or unable, to provide the required documentation. Employment must not take place until the required documentation is obtained. The manager stated that she maintains a training plan, on which she records staff training needs. An individual training record is also held for staff members and a number of these were seen. Training had been appropriately carried out, and included moving and handling, food hygiene, fire safety, first aid and health and safety. The manager advised that staff training needs are Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 19 discussed at supervision meetings and through direct observation of the work carried out by staff. The manager advised that training for staff in the care of people with dementia has yet to be arranged. It is required that this is carried out as soon as possible, to ensure the home can meet the needs of residents with dementia. An immediate requirement and another requirement have been made. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 20 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, 33, 34, 35, 36 and 38. A business plan and confirmation of business insurance cover need to be made available for inspection. Planned supervision of staff has started to be carried out. EVIDENCE: It was recommended at the last inspection that the manager be provided with allocated management time and office space to enable her to fulfil her duties. This was discussed with the providers, who stated that there is very limited office space available in the home. The opportunity to work at home has been offered to the manager, but this is not fully practicable as her work often involves documentation that is held in the home or telephone calls. The providers and manager advised that they would continue to look into this. A survey of the quality of the service offered by the home was carried out earlier this year and the manager advised that the results had been acted Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 21 upon. The manager stated that she planned to review and revise the questionnaire to make it more suited to the needs of the residents. It is required that an effective system of reviewing care and nursing is arranged. This must involve consultation with residents and their families or friends and copies of the outcome must be made available to residents and CSCI. The financial situation of the home was discussed with the providers. They stated that the home was viable, as they have been running it since 1987, but did not have a formal business plan available for inspection. No record was available regarding insurance of the business to cover loss or damage to the business or interruption of trading, which may prevent the providers meeting their financial liabilities. The providers stated that this information would be forwarded to CSCI, Surrey area office at Eashing. The provider stated that monies are not held for safekeeping on behalf of residents, as any extra charges are paid for by the home and invoiced to residents or their representatives, for reimbursement. Supervision of staff is now being planned and has started to be carried out the manager stated. The qualified nurses on the staff team have all received clinical supervision training to enable them to supervise staff working under them. The manager advised that by planning the supervision meetings, both parties have the opportunity to prepare any issues for discussion and staff have received the meetings positively. It was noted that the radiator covers in the upstairs lounge/dining room have still not been secured to the wall and present a hazard to residents and staff. This hazard was reported at the last inspection and a requirement was made. This remains unmet. A requirement has been made. Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 22 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X 3 X X X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 2 N/A 3 X 2 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 23 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 2 Regulation 5A Requirement Timescale for action 28/10/05 2 16 3 29 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. Unmet from 24/06/05. 22 (1 & 2) The registered person must establish a procedure (“the complaints procedure”) for considering complaints made to the registered person by a service user or person acting on the service user’s behalf. The complaints procedure shal be appropriate to the needs of the service users. 19(1)(a& The registered person must not b) Sch. 2 employ a person to work at the care home unless (a) he is fit to DS0000013372.V253956.R01.S.doc 02/12/05 27/09/05 Wray Common Nursing Home Version 5.0 Page 24 4 30 18 (1) (c) (i) 5 33 24(1)(a& b)(2&3) 6 34 25(2)(c& e)(3) (b&c) work at the care home and (b) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. Unmet from 25/04/05. The registered person must, having regard to the size of the care home, the statement of purpose and the number and needs of service users, ensure that persons employed by the registered person to work at the care home, receive training appropriate to the work they are to perform. Specifically, dementia training must be provided for staff. (1) The registered person must establish and maintain a system for (a) reviewing at appropriate intervals and (b) improving the quality of care provided at the care home, including the quality of nursing where nursing is provided. (2) The registered person must supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1) and make a copy available to service users. (3) The system referrd to in paragraph (1) must provide for consultation with service users and their representatives. The registered person must, if the Commission so requests, provide the Commission with such information as it may require for the purpose of considering the financial viability of the care home, including (c) information as to the financing and financial resources of the care home and (e) a certificate of insurance for the registered DS0000013372.V253956.R01.S.doc 23/12/05 23/12/05 28/10/05 Wray Common Nursing Home Version 5.0 Page 25 7 38 13 (4) (a) provider in respect of liability which may be incurred by him in relation to the care home in repsect of death, injury, public liability , damage or other loss. The registered person must ensure that the accounts give details of the running costs of the care home, including rent, payments under a mortgage and expenditure on food, heating and salaries and wages of staff ; and supply a copy of the accounts to the Commission at its request. The registered person must 27/09/05 ensure that all parts of the home to which service users have access are so far reasonably practicable free from hazards to their safety. Unmet from 25/04/05. 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 Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Surrey Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Wray Common Nursing Home DS0000013372.V253956.R01.S.doc Version 5.0 Page 27 - 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!