Inspection on 15/09/05 for Wychwood

This inspection was carried out on 15th September 2005.

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

Wychwood 10/11/08

Wychwood 14/05/08

Wychwood 03/01/08

Wychwood 13/08/07

Wychwood 15/11/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wychwood Headley Road Hindhead Surrey GU26 6TN Lead Inspector Catherine Campbell-Ace Unannounced 15 September 2005 10:30 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 v246886 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wychwood Address Wychwood, 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 Mumtaz 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 dis - over 65, 1 MD Mental Disorder, 1 OP Old age, 6 PD Physical disability, 1 PD(E) Physical dis - over 65, 5 Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 1 The age/age range of the persons to be accommodated will be: 65 years and over. 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. Date of last inspection 10 May 2005 Brief Description of the Service: Wychwood comprises of two properties, 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 which may be used as double occupancy. A number have ensuite facilities that include a toilet and basin, shower or bath. There are communal lounges and a dining room. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection lasted two and a half hours. The inspectors were Mrs Catherine Campbell-Ace, Regulation Inspector and Mrs Geraldine Yates, Pharmacy Inspector. The Registered Manager and Proprietor, service users and staff assisted the inspectors. Care plans and risk assessments were examined, together with pre admission assessments. Medication standards were assessed by Mrs Yates. What the service does well: What has improved since the last inspection? Since the last inspection, a new bath has been installed in the downstairs bathroom and decoration of bedrooms has taken place, together with fitting new carpets in the bedrooms. Window restrictors were fitted to upstairs windows and a ramp was now fitted to the lounge door in the bungalow. An inspection was recently made by the Environmental Health Officer; a requirement from the last inspection by the Commission for Social Care Inspection, who advised that the banister was too low for safety and must be raised. The work on this area is to begin on the 27th September 2005. Fire safety training has now been arranged and a Fire Risk Assessment is to be carried out on the 4th October 2005. Radiator guards were in evidence on some radiators, while unguarded radiators were cool to touch. The home has been awarded the Investors in People. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 7 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 v246886 300805 Stage 4.doc Version 1.40 Page 8 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) 3 A comprehensive assessment of needs is carried out before admission. EVIDENCE: It was evidenced that care plans contained an assessment of needs for each service user before admission, which included personal care and well being, continence, foot care, communication needs and medication usage. Service users said that they were assessed together with their family if they so wished. Long term goals were identified and reviewed regularly. No service user in this home is referred for intermediate care. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 9 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 Care plans are in place, but are unsigned by service user or representative. They are deficient in falls risk assessments, therefore not providing information needed to meet the service user’s needs in a safe manner. A review of medication handling was undertaken by a CSCI pharmacist inspector who concluded that the systems for the administration of medication, whilst safe, could be improved. EVIDENCE: Care plans contained assessment of needs and actions to be taken by care staff to ensure that all aspects of the health, personal and social care needs were met. They included details on current medication, sleep pattern, foot care, respecting choice and self-help skills. The care plans were unsigned by service users or representatives. Risk assessments were evidenced for eating and drinking, transfers and showering. No falls risk assessments were in evidence in care plans sampled. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 10 Medication stocks and records were sampled and showed that service users were receiving their medication as intended by their doctors. One service user was holding and administering all of their own medicines with a detailed written risk assessment covering this activity. Other service users were given their medicines by the care staff and records were kept of those medicines administered. Detailed procedures on how to administer and store medicines were available for the staff but there was little or nor information covering the supply, disposal and self administration of medication. Medication was stored securely for the protection of the service users. However one medication was found in the drug trolley in an unlabelled dosette box. Medication must not be transferred from the original pharmacy labelled container into a second container for later administration. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 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) EVIDENCE: Standards 12, 13, 14, 15 were assessed at the last inspection. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 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) EVIDENCE: Standards 16 and 18 were assessed at the last inspection. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 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, 26 The standard of the environment is satisfactory providing service users with a homely place to live. EVIDENCE: Service user’s bedrooms were homely and comfortable, and were personalised with their own possessions. An Environmental Health Report evidenced during the inspection advised the Proprietor to raise the height of the banister on the first floor. The proprietor assured the Inspector that this was to be carried out on the 27th September 2005. The home was observed to be clean, hygienic and free from unpleasant odours. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 14 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) EVIDENCE: Standards 27,29,30 were assessed at the last inspection. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 15 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) 35 The systems for safeguarding service user’s financial interests are satisfactory. EVIDENCE: It was evidenced that service users control their own money when they wish to, and all transactions of accounts including hairdressing and chiropody were recorded satisfactorily. Secure facilities were provided for the safe keeping of possessions and the manager stated that one service user deposited an item of jewellery in the safe, and this was recorded in her care plan. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 16 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 3 x x x Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 17 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. Standard 7 7 8 9 Regulation 15 13 13 13 Requirement Service users care plans must be signed by either the service user or representative A falls risk assessment must be carried out on all service users All risk assessments must be dated. All medication must be administered directly from the original labelled container to the service user and not placed into any secondary container for later administration by another carer. Clear and comprehensive policies and procedures for the receipt, recording, safe handling, selfadministration and disposal of medicines, specific to the home, must be produced Timescale for action 26/11/05 26/10/05 26/10/05 24/10/05 5. 9 13 26/11/05 Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. 2. Wychwood H58 s13845 Wychwood v246886 300805 Stage 4.doc Version 1.40 Page 19 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 v246886 300805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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