Inspection on 27/01/06 for Wray Park Care Home

This inspection was carried out on 27th January 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 Park Care Home 08/04/09

Wray Park Care Home 02/05/07

Wray Park Care Home 03/11/05

Wray Park Care Home 13/01/05

Wray Park Care Home 25/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Wray Park Care Home Wray Park Care Home 55 Alma Road Reigate Surrey RH2 0DN Lead Inspector Cathy Clarke Announced Inspection 27th January 2006 10:00 27/01/06 X10029.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 Park Care Home DS0000013843.V272742.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 and Care Homes for Adults 18 – 65*. 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 Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wray Park Care Home Address Wray Park Care Home 55 Alma Road Reigate Surrey RH2 0DN 01737 242778 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) Mr Antony Coomb Mr Antony Coomb Care Home 24 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (6), Mental disorder, excluding learning of places disability or dementia (4), Old age, not falling within any other category (19), Physical disability (2), Sensory Impairment over 65 years of age (4) Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 24 service users the home may accommodate up to two male/female service users who are over 59 years of age with a physical disability (PD) Of the 24 service users the home may accommodate up to two male/female service users who are over 59 years of age with dementia (DE) 3rd November 2005 Date of last inspection Brief Description of the Service: Wray Park Care Home is a substantial detached property that has been converted to provide accommodation for twenty-four service users. The home is owned and operated by Mr Anthony Coomb who is also the registered manager. The home is located in Reigate, near the M25. Access to shops, church, public transport and other local services are within easy reach. The accommodation for service users is provided on two floors with a complement of en-suite facilities. The standard of décor, fixtures and fittings is very high. The living spaces are shared in a number of communal areas dotted around the home. These comprise of the large lobby areas, comfortably furnished lounge and dinning room on the ground floor. In addition there is the Georgian room that is mainly used for social events, reading room or a quiet area for service users. The home is located in substantial grounds that incorporate a large maintained garden, mainly covered in lawn and with a number of prominent features. The home has a parking area for over fifteen cars. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over a period of 6 hrs and was the second inspection to be undertaken in the Commission for Social Care Inspection Year April 2005 to March 2006. The inspector has looked at the National Minimum Standards for both Older People and Younger Adults, as this is a mixed category home. The scores awarded relate to the majority category of the home, which is Older People. Lead Inspector Cathy Clarke was assisted throughout the inspection by the Registered Manager Mr. Anthony Coomb representing the establishment. A tour of the premises was conducted. Ten residents and seven staff were consulted during the inspection. Care plans, recruitment records, medication, health care, complaints, health and safety checks and staff training were also inspected. Comment cards were received from eighteen service users, twelve relatives, seven General Practitioners and one Power of Attorney. The inspector would like to extend her thanks to the residents, staff and management at Wray Park Hall for their assistance and hospitality. What the service does well: What has improved since the last inspection? The home has been awarded with “runner up” in the “Care Choices” best training by an employer of fewer than 250 staff since the last inspection. The home recently held an awards ceremony for staff in a local hotel to recognise the achievements of staff who have successfully completed their NVQ qualifications. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 6 The dining room has been redecorated and two toilets on the ground floor have been refurbished and new tiles fitted. The kitchen has been renovated since the last inspection. The garden has been landscaped and the gateway to the home has been restored. Maintenance to the Pillars, which are a National Monument are to commence. The service users laundry is now marked to ensure that the correct items of clothing are supplied to service users. Clear instructions have been given to staff and a designated member of staff regularly checks laundry items. Details relating to complaints are now logged in full in the complaints book. 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. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Intermediate Care is not offered by this home. All service users are assessed prior to moving into the home. EVIDENCE: There have been six new admissions to the home in the last twelve months. A completed pre-assessment admission form has been completed for newly admitted service users. Each service user has a photo on file and health screening has taken place. Some of the records sampled contained falls risk assessments. A more detailed account of daily requirements is recorded on the daily records. One of the service users Power of Attorney has commented that the service user has settled in well to Wray Park in spite of the trauma of having to give Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 9 up her home. A relative has commented that she is pleased with the level of care for both her Father in Law and her Aunt; two relatives in the same care home must be a good advert. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 Older People and 16,18,19 and 20 of Adults 18-65 The health needs of the service users are well met with regular review meetings. There is a clear set of medication policies and procedures in place for the administration and storage of medicines. EVIDENCE: Medication administration Records (MAR) were sampled, in the case of handwritten charts not checked by the GP, it is strongly recommended that these be checked by a second person and referenced back to the original prescription. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 11 Controlled medications were checked and counted as correct according to controlled drugs register. Controlled medications are witnessed and given by two members of staff. Morning and noon medications in blister packs were checked as correct. The practice of secondary dispensing into pots from the blister packs was discussed with the registered manager and an alternative storage solution was immediately ordered in response to remedy the situation and comply with the Pharmaceuticals Society Guidelines of 2003. The district nurse comes into the home to draw up insulin for one of the service users who self medicates. The box containing the insulin is locked and stored in the fridge. Personal care is offered in private and records sampled showed that service users receive regular health care checks. Of the eighteen comment cards received from service users the majority have confirmed that their privacy is respected and they are treated well. Discussion was held with the registered manager regarding a comment made by one of the General Practitioners and this has now been resolved. Please see recommendations section of this report. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 Older People and 12,13,17 Younger Adults Service users take part in various activities in the home and in the local community. The service provides a varied diet, which is planned with the service users input, and alternative choices are always available. EVIDENCE: The registered manager informed the inspector that they would be providing more activities for service users in response to the needs of service users. Activities are posted on the notice board. During the inspection service users were receiving aromatherapy and when questioned stated that it was very enjoyable. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 13 During the inspection the registered manager explained how one of the service users have been able to maintain links with family in the local vicinity and how they have facilitated this with risk assessments in place to ensure these visits can be undertaken safely. One of the service users has recently travelled the world with her son. All of the service users have stated on comment cards that they enjoy living at the home and feel well cared for. Lunch on the day of the inspection was potato and rosemary soup, fish pie and vegetables with a sponge pudding and custard. Alternatives are available and discussion was held with the cook and staff about one of the service users who does not always like what is on offer. The cook explained that alternatives are offered and she has consulted with family regarding his needs. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Older People and 22 and 23 Adults 18-65 The home has policies and procedures in place for dealing with complaints and safeguarding adults. EVIDENCE: There have been not complaints or adult protection investigations since the last inspection. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 Older People and 24 and 30 Adults 18-65 The layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. The décor within the home is of a high standard. EVIDENCE: Since the last inspection the dining room has been redecorated and two toilets on the ground floor have been refurbished and new tiles fitted. The kitchen has been completely renovated since the last inspection. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 16 The garden has been landscaped and the gateway to the home has been restored. Maintenance to the Pillars, which are a National Monument is to commence soon. The home is very clean and there was no evidence of mal odorous smells. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 Older People and 32,34,35 Adults 18-65 Recruitment policies and procedures are in place. Confidential records are stored in the Registered Managers office. Wray Park Hall has been awarded with “Runner up” in the best training employer of fewer than 250 employees. There were sufficient numbers of staff on duty and staff are trained and competent to carry out their roles. EVIDENCE: Staff enjoyed a recent award ceremony held in a local hotel to celebrate their successful achievement of their NVQ awards. According to the Workforce Development Plan 68 of care staff hold NVQ level 2 or above. Staff demonstrated their competency within their roles as carers and those staff interviewed during lunch showed that they have skills and knowledge in care. Recruitment records were sampled and these included evidence of Criminal Record Bureau Checks, application forms, references, staff photos, medical questionnaires, birth certificates, and qualifications. There is a workforce Training and Development plan in place, which identifies the training planned, Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 18 in progress and completed for the year. Each member of staff has an individual training and development programme. Since the last inspection and to add to the award of best employer of under 250 employees from Skills for Care 2005 the home has been awarded “Runner up” in the best training employer of fewer than 250 employees. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,38 Older People and 37,39 and 42 Adults 18-65 Service users and staff benefit from the management approach at the home providing an open, positive and inclusive atmosphere. Procedures are in place to safeguard service users money. Health and safety policies and procedures are in place and enforced. EVIDENCE: Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 20 There is a key worker system in the home with staff completing key worker records. Each service user has a daily progress report. Regular meetings are held with service users and staff. A questionnaire is sent out to family and representatives and a separate one is given to service users and staff. Feedback from these reports is used to evaluate the quality of care provision and provides a basis for any improvements that are necessary. Financial records are completed for one service user and invoices and receipts are sent to the commissioning authority. Most service users deal with their own money or through their relatives/power of attorney. Health and safety checks are conducted in the home and a satisfactory outcome to fire safety checks, legionella sampling, heating, ventilation, gas boilers, electrical equipment, electrics including the lift and stannah lift, air conditioning controls and the nurse on call system have been obtained. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 4 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 X 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 Page 22 NO 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations It is recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. Wray Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 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 Park Care Home DS0000013843.V272742.R01.S.doc Version 5.1 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. 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. 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