Inspection on 08/06/06 for Wray Common Nursing Home

This inspection was carried out on 8th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wray Common Nursing Home 27/09/05

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 Megan McHugh Key Unannounced Inspection 8th June 2006 09:30 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.V296309.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. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 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 Mrs Karin Edit Isabella Edgren 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.V296309.R01.S.doc Version 5.2 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). 27th September 2005 Date of last inspection 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 and 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. Fee ranges are from £526.00 to £812.00 per week. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the first to be undertaken in the Commission for Social Care Inspection year 2006 to 2007 and took place over six hours and forty-five minutes. The inspection was carried out by Mrs. M McHugh, Regulation Inspector and input was provided by Mr. S. and Mr. H. Segal, Registered Providers and the registered manager (matron). A full tour of the premises was undertaken and 20 service users, 1 visitor and 4 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. The Commission would like to thank the staff, service users and visitors for their hospitality and cooperation throughout the inspection process. What the service does well: What has improved since the last inspection? Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 6 The home has put in place new contracts which include a breakdown of the fees, method of payment and to whom the fees are payable to. A new complaints procedure has been developed and this now includes timescales for action and the person’s right to contact the Commission at any stage of the complaint process. The staff records sampled contained the information as required by Legislation and have records of registered nurse’s PIN numbers and expiry dates. Staff are now receiving specialist training in the form of Dementia awareness training and other areas. This was pleasing to see and staff stated that this has helped them do a better job. The providers have started a programme of quality auditing in the form of service user surveys and have plans in place to hold quarterly service user/residents meetings. They have yet to collate the findings of the survey and make this available to service users. The providers have provided the Commission with financial and insurance information that is satisfactory for the purposes of assessing financial viability. The areas identified in the last inspection as posing a risk or could be deemed unsafe for service users have been rectified and no longer pose any risk to anyone in the home. What they could do better: An immediate requirement was made in respect of the COSHH (Control of Substances Hazardous to Health) cupboard being found unlocked. This cupboard must be kept locked at all times when unattended by a staff member. A recommendation was made that daily notes/records are made more informative about what care was provided, any visitors, mealtimes, activities participated in etc. This will help substantiate the care provided to the individual service user. A recommendation was made that the providers collate the information provided in the returned service user surveys and make this available to service users and anyone else who requests this. Please contact the provider for advice of actions taken in response to this Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 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.V296309.R01.S.doc Version 5.2 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.V296309.R01.S.doc Version 5.2 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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All new service users have an updated contract/terms and conditions with the home; existing service users have the old version of the contract in place. All service users are assessed by people trained to do so, prior to admission into the home. The home does not provide intermediate care. EVIDENCE: The new contract now contains information about the breakdown of the fees, the method of payment and to whom the fees must be made payable to. This is an improvement on the previous contract agreement. All service users have a contract with the home in place. The registered manager discussed the pre-admission assessment procedure with the inspector and a copy of the assessment was seen. Occasionally the home uses the care manager’s pre-admission assessment and agreement of care needs if this incorporates similar areas that the home’s assessment covers. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are in place and local health care professionals support health-care needs. Medication administration appears to be carried out appropriately. The privacy and dignity of service users is respected. EVIDENCE: The care plans sampled were well-written, holistic in nature, comprehensive and were kept under review on a monthly basis. Any identified risks from the risk assessments were incorporated into the care planning process and clear action plans were available to minimise these risks. Each file sampled contained consent forms for use of bedside rails- if the risk assessment found that they are required to keep a service user safe, permission to take photographs and approval of the care plan to be signed by the service user; if able or their representative. This was commendable and was pleasing to see. The home is well supported by a team of GP practices and other local health care professionals including dentist, chiropodist, optician, aromatherapist and physiotherapist, to name a few. Part of the lunchtime medication round was Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 12 observed and this was carried out according to Legislation and in line with the home’s medication administration policy and procedure. No gaps were noted on the Medication administration records sampled and staff were aware of the disposals of medication procedure. Controlled drugs were not checked at this inspection. Service users stated that staff respected their privacy and dignity. Staff were observed during the day to be respectful of service users, calling them by their preferred name, knocking on doors prior to entering and providing personal care in a manner that provides the service user with dignity. One service user did state that staff do knock on the door but do not always wait to be told they can come into the room. However the service user also stated that sometimes they are not sure if staff are knocking on their door or their next door neighbour’s door and as they sit in their chair facing away from the door they can not see if there is some one at their door or not. No other comments of this nature were received. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure and social activities are available during the week. Service user’s visitors are welcomed at anytime and can use the lounges or service user’s bedrooms to meet. Meals are freshly cooked, looked appealing and wholesome and were provided in pleasing surroundings. Service users are supported to retain control of their lives and make their own choices. EVIDENCE: The home employs an activities person who works three afternoons a week. At the time of the inspection, the activities person was on leave, however a programme for the coming month was made available and included outside entertainers coming into the home. Staff have been allocated to provide activities during the leave period. The proprietor stated that the activities person goes around the home to as many service users as she can manage to visit a few hours before the planned activities to inform service users of the up coming activity and to spend a short while with service users who do not wish to join in the activity. A service user stated they do not like to attend the activities but the activities lady visits them at least once a week. The home does not restrict visiting hours and a few visitors were seen around the home at different times of the day. One visitor stated that they ‘pop in’ and Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 14 visit when they can and they are never told they cannot come in. A visitor stated that they have seen church ministers in the home providing a service for service users and they were very pleased to see this happening regularly. A number of examples of service users exercising choice were observed and some service users gave examples how they choose what they want to do or not do in the home. One service user discussed their choice to have their meals in their bedroom rather than in the communal dining room and another stated that they choose to attend activities or not. Staff were respectful of these choices and did not tell anyone they could not do that unless it was endangering the safety of the service user or others around them. The lunchtime meal was observed and there were three options of main meal offered. The inspector noted that one service user had requested a different meal to the three provided and this request was catered for. Service users stated that the food was nice and of a good quality. One comment received was that sometimes there is a rather long wait between courses being served. The home has three dining areas over two floors and staff have to provide meals to service users in their bedrooms. All the meals served were hot and although some service users had to wait a while between courses, this was understandable due to the layout and number of areas and service users to provide meals for. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear, provides timescales and advises the right to contact the Commission at any stage of the complaint. Service users are safeguarded from abuse. EVIDENCE: The home’s complaint procedure has been amended and now contains clear information about how a compliant will be dealt with, the timescales of dealing with a complaint and the complainant’s right to contact the Commission at any stage of the complaint. The home has not received any complaints since the last inspection. Staff have had training in safeguarding vulnerable adults from abuse and the home has clear policies and procedures in place. Staff stated that they had had training and were aware of reporting any concerns or allegations of abuse to the manager, proprietors or the Commission. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment in the home is good, providing service users with an attractive, safe, well-maintained and homely place to live. EVIDENCE: All areas of the home were seen and the standard of decoration within the home was observed to be from high standard in the newly built wing to a satisfactory standard in the older areas of the building. 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. Flowers and plants were placed around the home, creating a homely atmosphere. All areas of the home were clean and freshly aired. Wray Common Nursing Home DS0000013372.V296309.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet the needs of the service users. Staff are trained and competent to do their jobs. The standard of recruitment and vetting practices has improved and all the appropriate checks are now being carried out. EVIDENCE: The number of staff on duty and the mix of trained and care staff was seen to be satisfactory to the assessed care needs of service users in the home. It was also pleasing to note that the home does not use any agency staff to cover shifts. Staff were observed sitting with service users talking in communal areas, checking on service users in their bedrooms and assisting service user where required. It was pleasing to note that a number of the female service users were wearing make-up and jewellery. This indicated that staff take the time to ensure that those service users who like to wear make-up or jewellery are able to do so. A service user stated that staff always assist her to choose jewellery that matches her outfit and make sure her hair is combed and looks nice. One service user stated that staff sometimes take a while to answer the nurse call bell. No other comments about length of time to answer call bells were made during the visit. A list of staff training was seen and this matched up to certificates of attendance to the training days. It was pleasing to note that the home has Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 18 implemented specialist training relevant to the care needs of the service users in the home, especially care of people with dementia. At present there are only 11 of the 27 care staff with a NVQ (National Vocational Qualification) in care, however the home has a presentation due on the 15th June as an introduction to NVQs to encourage more staff to start their training. The proprietor stated and showed evidence that the home has registered with a training collage, however there are no available assessors to allow staff to start their courses. The home has an induction programme in place and a member of staff is in charge of overseeing all new staff member’s induction. One staff member was having induction on the day of the inspection. The staff files sampled contained all the information required including proof of identity, references, Criminal Records Bureau (CRB) clearance certificates and for trained staff, records of their Personal Identification Number (PIN) and the expiry date. The Commission has been provided with a list of these as part of the pre inspection questionnaire. Wray Common Nursing Home DS0000013372.V296309.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is fit to be in charge and the home is run in the best interests of the service users. Generally the health, safety and welfare of service users and staff are promoted and protected, although one immediate requirement was made in this respect. EVIDENCE: The registered manager has been in post since December 2005 and she was the deputy manager in the home for a number of years prior to becoming the manager. The staff and service users reacted positively towards the manager during the inspection processes and the staff team appeared to work well together. The providers stated that they have noticed a number of positive improvements to the service since the manager took up post. Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 20 All service users were provided with a survey in February 2006, although not all completed these or return the surveys. The providers stated that they had used the information from these surveys to improve areas of care and service in the home. Examples were given at the time. This information has not yet been collated and made available to service users or anyone else who would like the information. The provider has agreed to do this as soon as possible. A copy of the annual development plan for quality assurance was made available and this shows the home is working towards gathering more information from service users to help improve the service provided. Service user meetings are planned to be held three monthly and the providers had discussions with the inspector about other areas they can gather quality assurance information from. The providers showed a positive approach to wanting to improve their service using feedback from those who use the service or visit the service. The home was generally free from anything that could affect the health, safety and welfare of service users and staff. However the COSHH (Control of Substances Hazardous to Health) cupboard was found open and unlocked. This must be kept locked at all times when a staff member is not present. The home has recently had a fire risk assessments completed and evidence was seen of areas where they have rectified the highlighted risk. No other issues were found. Wray Common Nursing Home DS0000013372.V296309.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X X X 2 Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation Requirement Timescale for action 08/06/06 13(4)(a)(c All substances hazardous to ) health must be appropriately stored in a locked cupboard at all times unless in use by a staff member. An immediate requirement was made. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Daily notes/records should be made more informative about what care was provided, any visitors, mealtimes, activities participated in etc. This will help substantiate the care provided to the individual service user. The information gathered from the quality audit survey should be collated and a summary of the findings should be made available to service users, the Commission and anyone else who asks to see this information. 2. OP33 Wray Common Nursing Home DS0000013372.V296309.R01.S.doc Version 5.2 Page 23 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.V296309.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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