Inspection on 26/02/07 for Wychdene

This inspection was carried out on 26th February 2007.

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

Wychdene 20/07/09

Wychdene 16/12/08

Wychdene 19/02/08

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 Tina Thomas Key Unannounced Inspection 26th February 2007 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 Wychdene DS0000065494.V331110.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.V331110.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 Mrs J Gray Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Wychdene DS0000065494.V331110.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 17th July 2006 Brief Description of the Service: Wychdene residential home. It is owned by a private company. It is a large detached property situated in the village of Broadstairs. 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 . Fees range from£303-£ 375. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key unannounced inspection conducted in the year April 06- April 07. The inspection process took place over a period of time, information was gathered, and it concluded with a site visit conducted over one day. Judgements were made by taking into account evidence from a range of documentation, a tour of the home, discussion with service users, staff and the manager. The inspection was conducted with the assistance of the manager and deputy manager, who have been in post since August 06 following the last inspection. The new management team have worked hard to bring together a strong staff team. They have overhauled all systems of work that underpin a care service, for example, care planning, recruitment, training, policies and procedures and ensured that this is supported by good quality documentation. One requirement remains outstanding from the inspection of July 06, and further requirements were issued following this inspection. The new management team had already recognised where improvements need to be made, and are working towards completing this work. What the service does well: The service creates a homely environment for the people that live there. The service is flexible to meet the needs of the people who live there. The managers are aware of the homes strength and weaknesses, and together with the staff have worked towards improvement, so as to improve life for the people that live in the home. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 7 The Provider must conduct regulation 26 visits to show that he is aware of how the home is performing. Staff must have regular supervision. Supervision is an opportunity to discuss all aspects of practice, philosophy of care in the home, career development needs. The home must produce a fire risk assessment to ensure the safety of service users. The extractor fan in the smoker’s room does not effectively remove smoke and this isn’t pleasant for service users when they are using the dining room next door. 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.V331110.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.V331110.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): 1,2,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users with suitable information so as to enable them to make an informed choice. Service users have a suitable contract. The home currently ensures through a suitable assessment process, prior to admission, that peoples needs can be met. However, some existing service users have not had suitable assessments to ensure they are within the category of the homes registration. The home does not provide intermediate care and does not have the facilities, expertise and resources to do so. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 10 EVIDENCE: Prospective service users are given information about the home. The Manager has updated the 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 deputy manager has reviewed service user contracts and has corrected or removed information, which was incorrect. Service users do not move into the home without having their needs assessed. This is to ensure that the home can meet their needs. The new managers have created some new pre admission documentation. A review of a recently admitted service users initial assessment conducted by the deputy manager was of good quality. Some service users who have been funded by social services or the local authority have not had a summary of the Care Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes. This means that there is no evidence within the care plan to show what provision of care social services expect the home to provide. It is the registered persons responsibility to ensure that these plans are obtained. Some existing service users at the home may possibly be out of category of the homes registration. The manager must ensure that service users who demonstrate a lack of cognitive ability have their needs suitably addressed by an appropriate health care professional and a firm diagnosis made. A requirement was made regarding this matter at the last inspection and remains outstanding. If people at the home are diagnosed with dementia then the statement of purpose and service user guide must be updated to reflect this. The home does not offer intermediate care Wychdene DS0000065494.V331110.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The planning of care has improved but needs to be developed further. Medication policies and practices have been reviewed to ensure service users safety Management have adopted practices that ensure that the privacy and dignity of service users is protected. EVIDENCE: Each service user has a plan of care. These have become far more organised and developed since the last inspection. They contain information for staff pertaining to the way each service user chooses to be cared for. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 12 The manager discussed ways in which she intended to improve them even further. They contain suitable risk assessments. They have been reviewed three monthly or when necessary. This must be increased to monthly, or when necessary. The manager acknowledged that the recording of cognitive impairment needs to be more fully recorded and measured. Service users that are able to, have not been part of the care planning process. A recommendation regarding this was made at the last inspection. The manager has agreed that service users that are able will be included in their planning of care and monthly reviews. Service users personal and oral hygiene needs are met. There was evidence in care plans that service users had access to Gp’s and other health care professionals on a regular basis and advice sought when necessary. Nutritional screening and monitoring of weight is of good quality. The manager has reviewed the medication policy and procedure. Together with the deputy manager she has reinforced good practice in the administration of medication, to ensure the safety of service users. Staff administering medication have been suitably trained. A medication trolley has been purchased. Service users agreed that they were treated with privacy and dignity. The manager has ensured that a new telephone line with a separate telephone number to the homes has been installed, so that service users can have the use of a phone in private. Service users wear their own clothes. The manager has purchased extra towels and flannels so that each service user has their own. There is only one bedroom that is now used as a double room. This has been suitably divided to ensure privacy for both service users. Wychdene DS0000065494.V331110.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now has a programme of activities, which considers the preferences of service users. Service users are encouraged to maintain contact with family, friends and the community. Service users are encouraged to exercise choice and control over their lives Meals are wholesome and plentiful. 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 Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 14 go to bed when they chose to. They agreed that the programme of activities have improved recently, and now included coach trips. Service users agreed that their relatives were made welcome during visits. They agreed that their visitors were welcome at all times without appointment. Service users are encouraged to exercise choice and control over their own lives. Advocacy and self-advocacy is now discussed prior to admission. Service users have regular meetings that are minuted and actioned. 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. Care staff were observed assisting some service users in a discreet and patient manner. Hot and cold drinks together with snacks are offered to service users regularly. There are no service users who currently require special diet. Wychdene DS0000065494.V331110.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): 16,18 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. The home has suitable procedures, and training in place to ensure that service users are protected from abuse. EVIDENCE: The home has had no complaints since the last inspection. The home has a suitable complaints procedure. Service users are protected. All staff are trained in adult protection. The deputy manager is a trained trainer in adult protection. 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.V331110.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,26 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 some furnishings remain aged. Lack of a fire risk assessment puts service users at risk. The home has indoor and outdoor communal areas that can be enjoyed by service users. There have been improvements to the standard of people’s own rooms. The home is generally clean and odour free. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home is generally clean and free from odour. Some areas of the home i.e. the kitchen and external decoration need attention. However, there are plans for both these issues to be addressed this summer. The home does not have a fire risk assessment and therefore does not comply with the requirements of the local fire service and puts service users at risk. 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. The smoking room has an extractor fan, which is ineffective. It needs a more effective method of removing smoke. Smoke from the smoking rooms drifts into the dinning room, which is unpleasant for service users, and staff that do not smoke. Service users rooms now have new matching soft furnishings. Service users have their own towels and flannels. There has been a programme of renewal of the commodes and this is nearly completed. Some of the furnishings in the home are aged. 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. The home is clean, and has suitable laundry facilities. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient care staff to meet service users holistic needs. The homes practice regarding the recruitment of staff ensures service users safety. Staff receive suitable induction and foundation training. EVIDENCE: The manager, staff and service users all confirmed that they believed that the home was suitably staffed. The home has not met its target of 50 trained in NVQ Level 2 by 2005, however, the manager has addressed this matter. 20 of staff are trained to NVQ Level 2 and 50 of staff are enrolled on the NVQ Level 2 training. All new staff are enrolled on a Skills for Care training programme. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 19 The manager has reviewed all staff files and has ensured that suitable recruitment procedures have been put into place so as to ensure service user safety. All staff have CRB’s prior to commencing employment at the home. The deputy manager has taken responsibility for staff training. She is qualified to deliver much of the training herself. Other training has been sourced elsewhere. Training has included safe handling of medications, infection control and care skills. The home has an induction, which is in line with skills for care. Wychdene DS0000065494.V331110.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): 31,33,35,36,38 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 made significant improvements in the running of the home. However, she does not have a management qualification in care, and has not yet been registered by the Commission. The home is run in the best interests of the service users. Service users financial interests are safeguarded. Improvements have been made in regard to health and safety issues within the home, however further improvements need to be made to completely ensure service user safety. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is NVQ Level 3 qualified. She has four years management experience with older people in a domiciliary care setting. The manager and her deputy have facilitated a lot of change at the home and have overhauled most systems of work. Staff and service users expressed that they appreciated new working practices in the home. They liked that manager and found her approachable and considerate of their needs. The manager undertakes regular training. Although the manager meets with the Provider periodically, the Manager does not receive regular supervision. The registered provider does not fulfil his mandatory visits to the home. The manager should embark on a management qualification and apply to the Commission for registration so as to enable the fit person process to ensue. The manager has started a process of quality assurance. Surveys have been sent out to service users and their relatives. The manager is currently collating this information so that it can be evaluated. Policies and procedures within the home have all been reviewed. Sometimes action has not always progressed within agreed timescales to implement requirements identified in CSCI inspection reports. The home has developed a business and development plan. 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. Staff do not receive formal 1-1 supervision. Supervision is an opportunity to discuss all aspects of practice, philosophy of care in the home, career development needs. Generally, the health, safety and welfare of service users and staff are promoted and protected. The new manager has implemented risk assessments in care plans and environmental risk assessments. This has led to a reduction of falls within the home. However, as the home does not have a fire risk assessment service users are at risk. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 22 The registered manager ensures safe working practices and has facilitated mandatory training. She has ensured that staff now have appropriate induction and foundation training. Gas, electrical, hoist and other servicing were up to date. The Provider has not complied with regulation 26 visits, these visits must be conducted when the provider when he is not in day to day charge of the home, to ensure that the home is being conducted as it should be. Quality Assurance surveys have been conducted, they express that service users would like to go out more (the coach has been arranged) and furnishings should be improved. Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 23 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 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 2 x x 3 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 2 x 3 x x 2 x 2 Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement The home must ensure that people in the home who are demonstrating lack of cognitive ability are suitably assessed by an appropriate health care professional and a firm diagnosis made. Variations to the registration must be sought if necessary Previous requirement with timescale of 31/08/06 NOT MET 2 OP19 Schedule 4 23 The home must have a fire risk assessment, prepared by an appropriate person, on the premises The home must ensure that service users that do not smoke are not subject to the effects of other people smoking. 30/04/07 Timescale for action 31/03/07 3 OP20 30/04/07 4 5 OP31 OP36 26 18 The extractor fan in the smoker’s room is insufficient and this must be addressed. The Provider must conduct 01/04/07 regular regulation 26 visits Staff must be suitably supervised 01/04/07 Wychdene DS0000065494.V331110.R01.S.doc Version 5.2 Page 25 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 3 Refer to Standard OP7 OP21 Good Practice Recommendations Service users should sign their care plans as evidence of their agreement of it. One toilet does not have a sink. A solution must be found to promote good hand washing practice. 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