Inspection on 19/02/08 for Wychdene

This inspection was carried out on 19th February 2008.

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 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

Wychdene 20/07/09

Wychdene 16/12/08

Wychdene 26/02/07

Wychdene 13/07/06

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 Wychdene 19 Callis Court Road Broadstairs Kent CT10 3AF Lead Inspector Sandra Crosby Key Unannounced Inspection 19th February 2008 09:00 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 Wychdene DS0000065494.V358483.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. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wychdene Address 19 Callis Court Road Broadstairs Kent CT10 3AF 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) 01843 865282 Mylan Ltd Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of four (4) Service Users to be accommodated at any one time over a maximum period of 28 days. To admit one (1) Service User, whose date of birth is 22/06/1944. Date of last inspection 26th February 2007 Brief Description of the Service: Wychdene residential home is owned by a private company. It is a large detached property situated close to the town of Broadstairs. At the present time only one of the double bedrooms is being used as a double and all other bedrooms are currently being used as singles. Seven of the bedrooms have ensuite facilities. The home has a lift facility. The home is located in close proximity to local amenities. Wychdene is registered to provide personal care and support for up to 28 older people, who require varying degrees of assistance. The home has a new manager who as yet, is not registered with the Commission. The manager confirmed that currently fees range from £318 to £420. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate, quality outcomes. This report contains the findings of the home’s key inspection and takes account of information obtained from various sources since the last inspection of 26 February 2007, including a visit to the home. An unannounced visit took place firstly on the 19 February 2008 between 10:00 hours and 14.00 hours, and then on the 26 February 2008 between 09.30 and 12.30. The visit included talking to staff on duty, an accompanied tour of the home was made, and various records wee seen. A new manager has been appointed, and at the time of the inspection had worked at the home for three weeks. She has the necessary qualifications together with experience in managing a care home for the older person. The previous manager had completed and returned the Annual Quality Assurance Assessment (AQAA) documentation. Five completed service user surveys and three relative surveys have been received providing mainly positive comments about life at the home for example ‘staff are very good and very kindly’, ‘we are kept in the picture at all times and encouraged to give our views’ and ‘always a very happy and caring atmosphere in the home’. The findings of this inspection indicate that this home provides mainly good outcomes for the residents, but there are some areas in relation to health and personal care, staff training, the environment and some management aspects that although adequate, need some improvement. The manager is aware of what changes need to be made and is committed to making these improvements. The findings of the inspection visit were discussed in a verbal feedback with the manager at the end of the visit and by telephone with the registered person later that day. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Implement service user plans that contain all components as required by regulation. Ensure that the system for the administration of medication promotes the health and safety of service users. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 7 Staff practices promote dignity and respect of service users at all times. Increase the range of activities provided. Staff to undertake NVQ and mandatory training as required by regulation for example First Aid. Regular supervision implemented. of staff with written records maintained to be Introduce a quality assurance system. Further improvements required to the environment for example further redecoration. 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. The summary of this inspection report can be made available in other formats on request. Wychdene DS0000065494.V358483.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 Wychdene DS0000065494.V358483.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3 and 6 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users with suitable information to enable them to make an informed choice. The home currently ensures through a suitable assessment process, prior to admission, that peoples needs can be met. The home does not provide intermediate care and does not have the facilities, expertise and resources to do so. EVIDENCE: Prospective service users are given information about the home. It was reported in the last inspection report that the then manager had updated the Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 10 Statement of Purpose and Service User Guide, so that information given is current. The home no longer offers day care services and this is no longer included in the service user guide. The manager is currently reviewing all paperwork systems in the home, and will be making amendments as necessary. Service users do not move into the home without having their needs assessed to ensure that the home can meet their needs. Wychdene DS0000065494.V358483.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The planning of care needs and medication administration needs improvement to ensure service users safety. Management needs to look at staff practices to ensure that the privacy and dignity of service users is protected. EVIDENCE: Each service user has a plan of care. It was seen that some plans did not contain a plan of care, and there was no clear information in relation to regular reviews. The manager is aware of the components of required by regulation of a service user plan and said that she was currently working on a new care planning system, and that this was to be implemented over the coming months. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 12 Service Users health needs are mainly met; all service users have a named GP and attend appointments as necessary. A service user commented in a returned survey that ‘they always receive good medical support’. Since the manager started at the home, a controlled drugs cupboard has been installed, and a fridge for the storage of medication has just been delivered. The medication records were seen, and a number of gaps in recording were discussed. Staff have previously undertaken medication training, and further training is being arranged. Service users agreed that they were treated with privacy and dignity. However it was observed at the mid morning serving of drinks that service users were not asked what they would like to drink, or offered a choice of biscuit, but just given a drink and a biscuit. There was a lack of appropriate serving utensils used in order promote health and safety. This issue was discussed with the manager and she agreed to address this issue with staff. Wychdene DS0000065494.V358483.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are offered a small range of activities that enrich their lives. They are supported to maintain contacts with families and friends and enjoy a balanced and healthy diet. EVIDENCE: Service users discussed how they were happy at the home and how for some life at the home exceeded their expectations. Some service users discussed that they were able to retire to their room when they choose, and get up and go to bed when they chose to. They agreed that the programme of activities has improved, however action should be taken to increase the range of activities provided and for comprehensive records to be maintained to show the range of activities undertaken. One service user talked about a game they liked to play, and the manager said that she would take action to support this activity. A service Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 14 user commented in a returned survey that they ‘enjoy all the music and exercise’. Service users agreed that their relatives were made welcome during visits and agreed that their visitors were welcome at all times without appointment. Service users are encouraged to exercise choice and control over their own lives. It was reported in the last inspection report that advocacy and selfadvocacy is discussed prior to admission. Service users have regular meetings that are recorded together with the any action taken. Service users are encouraged to bring items from their own homes to personalise their own rooms. Service users agreed that meals are wholesome and plentiful. They felt comfortable in asking for what they wanted. A service user commented in a returned survey that the food was ‘good’. Food storage was seen and indicated that sufficient items were stored to provide a variety of nutritious meals. The records of the food provided were discussed with the manager, and she agreed that a full and comprehensive record should be maintained in order to provide evidence of the choices provided. The manager said that she would address this issue. Wychdene DS0000065494.V358483.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure, together with suitable procedures, and training in place to ensure that service users are protected from abuse. EVIDENCE: The completed AQAA documentation states that there have been two complaints in the last twelve months. The manager said there had recently been an adult protection alert raised and this was being investigated. A recent visit to the home by care management professionals has resulted in positive outcomes. Due to the positive action taken by the home, a letter received from the Registered Provider dated 19/03/08 confirms that the adult protection alert has now been closed. The home has a suitable complaints procedure. Staff are trained in adult protection to ensure that service users are protected. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 16 The policy and procedures of the home ensure service users finances are protected. Records are held and expenses sheets are sent regularly to service users families or representatives. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some areas of development and improvement within the environment, which has been prompted by the new manager. However further improvements are necessary to promote health and safety for service users and staff at the home. The home is generally clean and odour free. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 18 EVIDENCE: Service users have access to a variety of communal space. The home also has garden areas, which can be enjoyed. Furnishings and lighting are domestic in nature, although some furnishings in the home have become aged. It was seen during the accompanied tour of the home that some of the bed linen is in needs of replacement, and the manager agreed to undertake an audit in order to ascertain what new supplies were needed. It was reported in the last inspection report that only one double room is now in use. Service users who were in shared rooms, which did not offer sufficient space, have now been moved into single rooms. It was noted that several of the toilet doors did not have appropriate locks, and the manager agreed to address this issue. In order to promote good infection control practices staff must not carry soiled items through the dining room as was seen at this visit. The manager said that this would be further discussed with staff. Although the laundry facilities have been in there current location for many years, it was discussed that it is time that action is taken to provide a more suitable location for laundering, together with the installation of an appropriate sluicing area in the home in order to promote health and safety for the service users at the home. The central heating system has been fully serviced and is currently working well. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an enthusiastic and supportive staff team, however further staff training is required in order to ensure the health and safety of service users. The homes practice regarding the recruitment of staff ensures service users safety. EVIDENCE: The staff rota was seen, and it was indicated at the time of the visit that there were sufficient staff on duty to meet the needs of the current group of service users. The home has not met its target of 50 trained in NVQ Level 2 by 2005. The manager is addressing this matter. Staff files seen contained all relevant documentation as required by regulation. It was reported at the last inspection visit, that the home has an induction, which is in line with skills for care. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is competent and has relevant qualifications, although as yet not registered with the Commission. She is endeavouring to make significant improvements in the running of the home. Improvements have been made in regard to health and safety issues within the home, however further improvements need to be made to further ensure service user safety. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is NVQ Level 2,3 and 4 qualified, together with having completed the Registered Managers Award. She has previous management experience with older people in a care home setting. The manager is endeavouring to make the necessary changes needed at the home in order that all regulations are met. Staff and service users expressed that they appreciated new working practices in the home. They liked the manager and found her approachable and considerate of their needs. The registered person is now completing the required Regulation 26 reports, and it was discussed that it would be beneficial if the information contained in the reports were more comprehensive, as these could be used as a component of the quality assurance system to be implemented at the home. Service users financial interests are safeguarded. Written records are maintained of all transactions. The home has secure facilities for the save keeping of money and valuables. The manager is completing a staff training matrix, and it is indicated that staff require to undertake mandatory training in for example First Aid, COSHH, Moving and Handing, Infection Control etc. Staff do not currently receive formal 1-1 supervision with written records maintained. Supervision is an opportunity to discuss all aspects of practice, philosophy of care in the home, career development needs. The manager stated that this would be implemented for all staff in the near future. A system of quality assurance needs to be implemented, and the Manager said that this issue would be addressed. Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 2 Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Timescale for action A service user plan of care 30/06/08 generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered Provide a plan of care and evidence that this plan is regularly reviewed 2. OP9 13(2) The registered person ensures 31/03/08 that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines The registered person shall make 31/03/08 suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users Provide appropriate necessary locks as Requirement 3. OP10 12(4)(a) Improve staff practices in relation to the serving of drinks Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 24 and biscuits 4. OP19 16 & 23 The location and layout of the 31/03/08 home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance Maintenance programme to be ongoing with written records maintained Audit of bed linen to be undertaken and replacement provided as necessary Ensure effective infection control procedures are in place 5. OP33 24 Effective quality assurance and 31/12/08 quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home The registered person ensures 31/03/08 that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice Implement regular staff supervision The registered manager ensures 31/12/08 so far as is reasonably practicable the health, safety and welfare of service users and Mandatory staff training in for example First Aid, Moving and Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 25 7. OP36 18 8. OP38 18 Handling, Control etc COSHH, Infection 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 Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wychdene DS0000065494.V358483.R01.S.doc Version 5.2 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. 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