Inspection on 10/11/08 for Wychwood

This inspection was carried out on 10th November 2008.

CSCI found this care home to be providing an Adequate service.

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 14/05/08

Wychwood 03/01/08

Wychwood 13/08/07

Wychwood 15/11/06

Wychwood 15/09/05

Wychwood 10/05/05

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 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Lesley Garrett Unannounced Inspection 10th November 2008 10:45a 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 Wychwood DS0000013845.V373005.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. Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wychwood Address Headley Road Hindhead Surrey GU26 6TN 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) 01428 607014 wychgroup@hotmail.com Mrs Mumtaz Minaz Lalani Mrs Mumtaz Minaz Lalani Care Home 24 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (14), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (6), Physical disability (1), Physical disability over 65 years of age (5) Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2008 Brief Description of the Service: Wychwood care home is registered to provide personal care and accommodation for up to 24 older people, including people with physical disabilities, mental disorders and dementia. The registered premises comprise of two separate buildings, which are known as Wychwood, which is a detached two- storey building and Wychdale, which is a detached bungalow. There are a total of 18 single and 3 shared bedrooms all with emergency call bells and washbasins. Some have en-suite toilets facilities and others have en-suite showers or bathrooms. Assisted bathrooms and toilets are also available on all floors. Wychwood has a communal lounge and separate dining room and Wychdale has a combined lounge/dining room and domestic style kitchen. Service provision includes opportunity for community activities in the home’s wheelchair accessible vehicles. The provider is also the named registered manager. Weekly fees ranged from £434 to £745. Additional charges apply for newspapers, hairdressing, chiropody, some community outings, entertainment, aromatherapy and reflexology. Wychwood DS0000013845.V373005.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 the people who use this service experience adequate quality outcomes. This inspection of the care home was an unannounced ‘Key Inspection’. Mrs L Garrett, Regulation Inspector, and Mrs Janet Denyer, Regulation Manager, carried out the inspection and later after lunch the Registered Manager took the formal feedback and assisted the inspectors with inspecting the records. The Registered Manager is also the home’s provider and for the purposes of this report the person in charge will be referred to as the manager. The inspectors arrived at the service at 10:45 and were in the home for five hours. It was a thorough look at how well the home is doing. It took into account information provided by the home and any information that CSCI has received about the service since the last key inspection in May 2008, and the Random inspection in July 2008. Several requirements were made during the key inspection in May 2008 and therefore a random inspection took place in July 2008. At this random inspection it was found tht the manager/provider had complied with all of the requirements made. The inspectors spent time talking with some of the people living at the home in order to seek their views about the home and the care they receive. The home was not asked to supply a further AQAA (Annual Quality Assurance Assessment) as the homes last quality rating in May 2008 was poor the same AQAA was used for this key inspection. The inspectors looked at how well the service was meeting the key national minimum standards and complying with the regulations and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the home’s Statement of Purpose and Service User Guide, care plans, daily records and risk assessments, medication records, staff files, a variety of training records, and the home’s safeguarding and complaints policies and procedures. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Wychwood DS0000013845.V373005.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: Duty Rotas should clearly state who is managing the care of people who use the service on the “floor” each shift, so that relatives and allied professionals are able to identify who is accountable for the care needs that day. This is especially necessary on days when the Registered Manager is busy with their dual role as provider and is required to attend external meetings or managing the wider role of the provider and working in the outside office. The deputy manager currently carries out staff training. People who use the service would be better protected and the management’s accountability under Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 7 Health and Safety would be better if an external trainer carried out this training. Odour Control in some areas could be more effectively managed. 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. Wychwood DS0000013845.V373005.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 Wychwood DS0000013845.V373005.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): 13&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who wish to use the service have access to current information about the home, which allows them to make an informed decision about an admission. EVIDENCE: The manager stated that there have been no recent admissions to the home. Care plans were sampled, during the inspection, of three people using the service and pre-admission assessments were in place for them. The manager stated that either herself or the deputy manager would complete preadmission assessments prior to anyone moving into the home. The manager showed us the service user guide and statement of purpose and both documents contained information about the home, the staff and the services it provides. Information is also available about fees and details the services that are not included in these fees. Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 10 Wychwood DS0000013845.V373005.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 adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments have begun to be developed to ensure that they accurately reflect the current needs of the people using the service. People who use the service healthcare needs are met in a dignified way and medication administration has improved. EVIDENCE: Since the last key inspection in May 2008 the home has adopted a new system for recording information in care plans. The Care Plans were inspected for compliance during the random inspection, during this visit a small sample of three were again inspected. All three demonstrated risk assessments, daily records and activities. They are now produced in a “paper format” which allows, for instance, access to care staff, visiting professionals and the regulators. Some areas of the plans are, according to the Registered Manager, still being developed and expanded on. For example one persons file contained evidence of challenging behaviours currently being monitored by staff. The Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 12 record was not yet complete for demonstrating fully the action being currently taken to address these issues. Care Plans had been reviewed but they are still not signed by the person receiving the care or there representative. A person centred approach to care provided is required rather than routine especially for people who have cognitive problems. The manager said that this documentation is used for all people using the service and consultation takes place with the person using the service or their representative. Nutritional risk assessments were now in place for all three care plans sampled. Records indicated that healthcare professionals visit the home and individuals attend appointments, which included an optician, dentist and chiropodists. The manager said that the home has the benefit of a prescribing nurse specialist from the local general practitioners (GP) and visits the home every week to review any person using the service that the person in charge thinks needs to be seen. On this inspection the lunchtime mediation round was completed whilst we observed lunch being served. The manager stated that following the last inspection staff have received further training in the administration of medicines and observed supervision of practice is carried out to assess staff. We observed staff knocking on bedroom doors and speaking courteously to individuals. Arrangements are in place for people using the service to receive their visitors and visiting professionals in private. Wychwood DS0000013845.V373005.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 adequate. This judgement has been made using available evidence including a visit to this service. The staff on a regular basis provides activities that are available for people who use the service. A well balanced diet is also offered to all people in the service. EVIDENCE: It was observed that people moved freely around their home and had a choice to sit in the lounge, dining area or to spend time in the privacy of their own bedrooms. On the day of the inspection one member of staff was in the lounge assisting three people who use the service to play carpet golf. In the background music was playing and the television was on in the corner of the room. Two people using the service was watching the television but the sound was turned off therefore the sounds they were hearing in the room did not match what was being said on the television. On the notice board it was displayed the two main activities that would take place for that week and this was a quiz and ‘music mania’. There are additional charges for entertainers who visit the home. People using the service are invoiced for these sessions and this is stated in the home’s statement of purpose and contract. The manager said that the home has a new visiting Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 14 vicar from the local church who visits every month and that people who use the service also go out to church on Sunday. The manager stated that not many of the people using the service are able to visit the church now. The manager told us that added to the activity programme was baking with the assistant cook. She stated that the cook will make the cakes and then the people using the service will decorate the cakes that will then be enjoyed for afternoon tea. On the day of inspection there were no visitors to the home although the manager stated there are no restrictions to visiting times. Catering arrangements are well organised. The chef works in the home six days a week and a relief cook is employed on his day off. He is aware of the food preferences of people using services and of any dietary needs. The menu is displayed on the wall in the hall outside the dining room in Wychwood. The day’s menu is written on an orientation board in the dining room that also has other information about the date, day and weather. The menu is also available in the dining room in Wychdale. The manager stated that they had recently had an environmental health inspection and no requirements or recommendations were made. The manager also confirmed that she would consult with the environmental health department for advice when the building work starts and the home re-sites and re-builds the kitchen. Wychwood DS0000013845.V373005.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff have received safeguarding adult training and know the procedure to undertake if harm or abuse is suspected. EVIDENCE: The records sampled for staff showed that CRB checks had been carried out. One members of staff file showed that the good practice recommendation to recheck CRBs periodically had not occurred. A discussion with the registered Manager and Registered provider confirmed that this was designed to protect service users and the provider. It was agreed that this would be reviewed and implemented as appropriate. The complaints log was observed and this showed that no complaints have been received by the home since the last key inspection in May this year. The home’s complaint procedure is included in the service users guide file. We received a Regulation 37 notification prior to the inspection. This was discussed with the manager prior to the key inspection to consider passing the notification to the safeguarding adults team. The manager stated that she had not considered this but would now consider completing a referral. On the day of inspection the referral had not taken place but the manager stated that the GP was due to visit to assess the person using the service and that she would Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 16 do a referral that afternoon. Following the inspection a phone call to the deputy manager of the home confirmed that the referral had now taken place. The manager confirmed that all staff had received safeguarding training and that she and the deputy would access the local authority’s training also. Wychwood DS0000013845.V373005.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): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service live in a clean home and will benefit from the proposed refurbishment of the home in the very near future. EVIDENCE: The people using the service live in a safe environment, where they are able to have their own possessions around them if they wish. Door locks are provided on all rooms in the house and bungalow, the use of keys by people who use the service was not discussed at this inspection. The front door has a keypad security for exiting the home and one person currently has access to the community without assistance from staff. Hoists for bathing were in place and were being appropriately maintained. With the exception of one person using the service, who is bedfast, people who use Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 18 the service currently were seen to be able to walk around the home without the use of wheelchair assistance. The outside of the building is accessible in part and has barriers to areas that are demarked by railings ready for planned building works as yet not completely approved by the planning authorities. The exit to the fire muster point is accessible through double doors with break glass locks. The house and bungalow were observed to be cleaned to a very high standard. Carpet cleaning is carried out and this is done more frequently in rooms were there is an odour problem. Measures to manage the odour are in place but this was discussed with the manager, as this was not sufficient to eliminate the entire problem. Wychwood DS0000013845.V373005.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): 27 28 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training, induction and recruitment practices in the home have now been strengthened to protect the people using the service. EVIDENCE: Training records indicated that people who use the service are well cared for by senior care staff that have received mandatory training. All care staff benefit from cascaded training in safeguarding adults (abuse awareness) and challenging behaviours. Training records were sampled for two senior members of staff and they evidenced that training has been provided in safeguarding adults. There was evidence in both these and other staff records that the Deputy Manager and the Registered Providers have cascaded this training to the majority of staff members. People who use the service would be better protected if all staff received this training from an external accredited trainer. Records were seen that showed mandatory training for the majority of care staff had been undertaken. The manager confirmed that a new more visually accessible training matrix was being put in place that would allow the manager to quickly identify any individual care workers training needs. Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 20 The numbers and skill mix of staff meets people who use the service needs. The staff rotas are displayed in the service and a discussion took place with the manager to ensure that only the actual times that the manager is in the building should be displayed on the rota to avoid any confusion (see management and administration). Requirements made in the last inspection in May were seen to have been met at the Random Inspection on 27/7/2008. Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements at the home have improved since the previous inspection, which will benefit the people who use the service. EVIDENCE: The manager continues to be shown as working in the service even when her deputy or senior care workers are in charge of the home. During our feedback at the conclusion of the visit the manager agreed that in order to be clear they would rectify this immediately to show only the hours she is in the building. A requirement will be made at the end of the report. Records show that the deputy manager is assisting with training and supervision of staff and overseeing the service when the manager is not on Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 22 site. There are plans for the deputy to become the registered manager and she has obtained her CRB form for CSCI to begin the process. The manager stated that it is planned to send surveys to people who use the service, their relatives or representatives and healthcare professionals at the end of November. The manager stated that they have recently been audited for the Investors in People award. The inspectors were informed that although they have retained their accreditation the home has been required to do further work towards the award. It was stated that meetings with people who use the service are held regularly but only in Wychdale. Minutes of these meetings are kept. The home does not hold any allowances for the residents on the premises. The organisation does hold a deposit of £100.00 to meet any out of pocket expenses when people leave the home. The manager stated that a refund is given when the resident dies or leaves the home. The manager stated that all health and safety certificates are current and this includes those for the gas, electricity, boiler, fire alarms and the hoists. Wychwood DS0000013845.V373005.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 24 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 OP31 Regulation 18 Requirement Rotas must accurately reflect the hours that the Registered Manager is on site in her capacity as the Manager rather than as the registered provider. This is to enable accurate records and accountability Timescale for action 31/12/08 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 Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone 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 Wychwood DS0000013845.V373005.R01.S.doc Version 5.2 Page 26 - 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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