Inspection on 10/05/05 for Wychwood

This inspection was carried out on 10th May 2005.

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

Wychwood 10/11/08

Wychwood 14/05/08

Wychwood 03/01/08

Wychwood 13/08/07

Wychwood 15/11/06

Wychwood 15/09/05

Wychwood 14/02/05

Wychwood 26/10/04

Wychwood 02/03/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

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

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Catherine Campbell-Ace Unannounced 10 May 2005 10:45 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 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. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wychwood Address Headley Road, Hindhead, Surrey, GU26 6TN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01428 607014 Mrs Mumtaz Minaz Lalani Mrs Mumaz Minaz Lalani CRH Care Home 24 Category(ies) of DE Dementia, 3 registration, with number DE(E) Dementia - over 65, 14 of places LD(E) Learning Disability - over 65, 1 MD Mental Disorder, 1 OP Old Age, 6 PD Physical Disability, 1 PD(E) Physical Disability - over 65, 5 Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 65 years and over. 2. Additionally, three named service users in the category DE (Dementia under the age of 65 years) may be admitted, as per letter dated 12th February 2004. 3. Additionally, one named service user in the category PD (Physical Disability under the age of 65 years) may be admitted, as per letter dated 12th February 2004. 4. Additionally, one named service user in the category MD, excluding learning disability or dementia (mental disorder - under the age of 65 years) may be admitted, as per letter dated 21st March 2005. 5. Additionally one named service user in the category LD(E) learning disability over 65 years of age may be admitted, as per letter dated 12th February 2004. Date of last inspection 14 February 2005 Brief Description of the Service: Wychwood comprises of two properties, Wychwood and Wychdale. Wychwood is a large detached property and Wychdale is a detached bungalow and forms part of the Wychwood registration, both the properties are set in the grounds with attractive garden areas. The proprieter is also the Registered Manager, and operates the business with a staff team. The service provides 24-hour care for up to 24 adults with a varied range of needs. All bedrooms are used as single occupancy, with the exception of three that may be used as double occupancy. A number have en-suite facilities that include a toilet and basin, shower or bath. There are communal lounges and a dining room. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection lasted six and a quarter hours. The inspectors were Mrs Catherine Campbell-Ace and Mr John Chivers. The Registered Manager and Proprietor and Deputy Manager, Ms Cheryl Blanchard assisted the inspectors. Care plans and risk assessments were inspected and were written clearly to assist the service users in achieving their goals and aspirations. Policies and procedure, medication records and recruitment files were also inspected. The service users stated that they were happy and were well presented and dressed smartly. They attend activities within the home and occasionally go out shopping. The home has a medium sized lounge and dining room, where service users were observed to be chatting freely with staff. What the service does well: The service users looked very well presented and well-turned out. When they were asked about the home they said that they enjoyed living there and the staff were very kind. Religious services were available both inside and outside the home. The service users in the bungalow said that it was very comfortable, and enjoyed the company of the other service users. While the inspectors were visiting, the service users were enjoying tea and home made cakes. They said that the food was very good and they had a choice of meat, fish or vegetarian food. Diets were catered for. The service users spoke very highly of the staff and said that they were ‘lovely’. Staff were observed to be supportive towards the service users, in a homely atmosphere. The home has plans for a new kitchen and to build further bedrooms. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Service users have opportunities to make choices and have access to activities in and outside the home. It offers a very high standard of care and support to the service users but requirements have been made. A written Fire Risk Assessment must be made together with the assistance of the Fire Service, and regular fire training to be carried out by staff. The radiators in the rooms upstairs were found to be very hot. Guards must be bought and placed over these radiators. For safety reasons, windows on the upstairs bedrooms and bathrooms must have restrictors put on them, and the low banister in the upstairs hall must be inspected for safety by the Environmental Health Officer. The upstairs banister was observed to be low, and a requirement has been made for the Environmental Health Officer to examine it for safety The service users in the bungalow stated that the wheelchair access to the bungalow was very difficult. The inspectors demonstrated the difficulty to the staff and other service users, and found that for manual handling purposes, the access was poor. The Manager must improve wheelchair access to this building. The staff rest room, which included the medication trolley, was very untidy and cluttered, with damp water- marks on the wall. The proprietor assured the inspectors that the damp had been rectified. A recommendation has been made for this room to be tidied up and decorated. A requirement has been made for a Controlled Drugs cupboard to be provided for the secure storage of any Controlled drug including Temazepam, which are prescribed for service users, and that a Controlled Drug register be provided for the secure recording of any CDs including Temazepam. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 7 Care plans were evidenced and found to be comprehensive, however, they were in need of review. A requirement has been made that all care plans are reviewed. 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. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5 The service users are informed of the home of their choice, are able to assess the quality, suitability and facilities of the home, and know that this will meet their needs. EVIDENCE: A comprehensive service user guide was evidenced, together with pre admission assessments. Service user contracts were evidenced which stated the terms and condition of the home. The Manager stated that the service users were assessed together with the family and were able to visit to assess the quality, facilities and suitability of the home. It was noted that the service users had a trial period of one month, to ensure that they were satisfied with the home, and whether the home was suitable for them. This could be extended if necessary. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10, Care plans were evidenced to be comprehensive and clear, setting out the care needs of the service users, although some care plans sampled, needed updating. EVIDENCE: Care plans were evidenced and found to be comprehensive. They included families and service users views on the care plans and signed by relatives or service user. Two care plans evidenced required updating. The plans included health needs, personal hygiene needs, continence assessments, mobility, foot care, dental care, sleep pattern, behaviour patterns, social skills activities and community skills. No service users self-medicated. Mar forms were signed for medication given, the medication trolley was in need of cleaning and tidying and the room in which the medication was held was untidy and cluttered. Controlled drugs were found in the drugs trolley, which were not counted, signed and countersigned. The service users told the inspectors that they enjoyed living in the home. They said that the staff were ‘lovely’ and ‘kind’ They spoke very highly of the Deputy Manager. A staff member was observed to knock on a service user’s door during the inspection of the premises. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15 The home offers opportunities for the service users to choose their lifestyles and encourages visits from relatives. The home offers choice within a wellbalanced diet. EVIDENCE: Whilst the inspectors were talking to the service users, they stated that their expectations had been met, but they would like to go out more. One service user said that she never goes out. Service users said that they could receive visitors at any time without restrictions. It was observed that visitors could meet with their relatives in the privacy of their rooms. The service users said that they were very happy in the home and they had no complaints. They said that they were able to choose the activities that they could attended The service users said that the food was very good and it was observed that they received home made cake for their afternoon tea. Menus were evidenced to provide a varied and balanced diet. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 12 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 standard(s) 16,17,18 The manager had acted upon service users complaints, but no complaints had been received since the last inspection. EVIDENCE: A complaints policy was evidenced, and the service users knew to whom they could complain. The manager stated that service users had participated in the civic process, and had been able to either use a postal vote or had been taken to the polling station by a staff member. When asked, the service users stated that they had voted. Staff were trained in Protection of Vulnerable Adults, and were aware of the procedure to follow if they suspected abuse. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,22,23,24,25,26 The home was clean, with hand basins in all bedrooms, but it was observed that some areas may not be safe, and requirements have been made. EVIDENCE: It was observed that the banister at the top of the stairs was low and the Manager was asked to contact Environmental Health for a report on its safety. The windows in the upstairs bathroom and one bedroom inspected, opened out and were a risk to service users. A requirement has been made for restrictors to be placed on all windows upstairs, for the safety of the service users. All washing facilities and lavatories were observed to be sufficient, but it was noted that one bathroom downstairs was out of order because bath equipment was broken. The service user’s bedrooms were homely and comfortable, and were personalised with their own belongings. In one of the bedrooms it was noted Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 14 that the radiator was very hot to touch, and required a protective guard. Several other radiators in the corridor were also hot, and a requirement has been made to provide protective covers for all uncovered radiators. The service users in the bungalow were very concerned that they could not access the bungalow independently, and the inspectors demonstrated the difficulty staff experienced when wheeling the service users in and out of the doors. A requirement has been made to install a ramp for easy and independent access to the bungalow. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The home employs local staff and staff from Eastern European countries. The recruitment procedures are satisfactory which offers protection to the service users. EVIDENCE: Recruitment records were evidenced, which followed the home’s recruitment policy. References, CRB checks, and registrations from the Home Office were evidenced. The home employs its own staff and does not use agencies. The Deputy Manager works six days out of seven, working half days on weekends. The inspectors discussed working practices with a member of staff who said that she was very happy at Wychwood, and was inducted well into the work. Training records were evidenced, and were found to be deficient in fire training. The inspectors were informed that the staff received fire training on induction. A requirement has been made in respect of this finding. The Eastern European employees have been provided with English lessons. One Eastern European staff member spoke good English and when asked about emergency assistance for the service users, answered competently. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,37,38 The service users receive good quality of care and said that they were very happy. They looked well cared for and smartly dressed. Care plans were comprehensive, but needed updating and there were areas of concern regarding the safety of the residents EVIDENCE: The service users looked smart ad well cared for. They praised the staff, especially the Deputy Manager, and said that the other staff members were kind to them. Some service users were smoking outside when the inspection took place, and the staff were concerned that they didn’t have a smoking room within the building. The Statement of Purpose did not address this subject. It was evidenced that service user’s financial interests were safeguarded. Policies and procedures were in place and had been updated since the last inspection and care plans were comprehensive but needed updating. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 17 Staff supervision records were evidenced and it was noted that staff received regular supervision and training. A requirement has been made for the Manager to write a Fire risk assessment, the banister on the stairs needs checking by Environmental Health Officers, restrictors must be fitted to the upstairs windows, and the hot radiators must be covered with guards. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 3 3 3 2 2 3 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 Standard No 16 17 18 Score 3 3 3 x x 3 x 3 3 3 2 Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 19 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. 1. 2. 3. 4. 5. 6. Standard 19.5 38 25.5 22.2 19 19 Regulation 23(4)(a) 23(d)(e) 13(4)(a) 23(b) 4(a) 4(a) Requirement A Fire risk assessment for the building must be written Regular fire training for staff must be arranged and fire drills carried out. Radiators must be guarded A ramp must be provided for access to Wychdale Restrictors must be fitted to all rooms on the upstairs rooms. The banister rail on the top of the stairs must be asessed for safety by the Environmental Health Officer Service users plans are to be reviewed The staff room/medication store must be tidied and redecorated. The bath chair must be repaired in the upstairs bathroom. A controlled drug cupboard which complies with the Misuse of Drugs(Safe Custody ) Regulation 1973 is provided for the secure storage of any Controlled Drugs including Temazepam, which are prescribed for servic users. Timescale for action 10/07/05 10/06/05 10/06/05 10/06/05 10/07/05 10/07/05 7. 8. 9. 10. 7 19 22.4 9 15(2)(b) 23(2)9d) 23(2) 2 10/05/05 10/07/05 10/06/05 10/06/05 Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 20 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. 2. Refer to Standard 4 9 Good Practice Recommendations It is recommended that a full reassessment of needs be carried out on the service user in hospital, on her return to the home. It is recommended that a Controlled Drugs register, which is a bound book with numbered pages, is provided for the secure recording of any Controlled Drugs, including Temazepam,which are prescribed for Service Users. Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 Wychwood H58_s13845_Wychwood_v224792_100505 stage 4.doc Version 1.30 Page 22 - 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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