Care Home: Selkirk Wing

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What the care home does well All new people receive a comprehensive needs assessment before admission. This is carried out by staff with skill and sensitivity. The home consults people using the service about their satisfaction with the service they are receiving. The home has a medication policy which is accessible to staff, medication records are up to date for each individual and medicines received, administered and disposed of are recorded. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet people needs. People who use the service are able to express their concerns, and have access to an effective complaints procedure, and are protected from abuse, and have their rights protected. The management and administration of the home is based on openness and respect, and has an effective quality assurance system.Selkirk WingDS0000019120.V376067.R01.S.docVersion 5.2 What has improved since the last inspection? The home has recently completed the accreditation process for the Gold Standards Framework in end of life care and use advanced care plans and priorities of care for all the people that use the service. The Commission recognises the good work that goes into achieving this standard and the hard work of management and staff. There is now a plaque at the service stating “This home has been awarded the Gold Standards Framework Care Homes Association Award for the high quality of care provided for people in the final years of life”. A post bereavement support network has also been setup by the home where families are contacted six weeks after the death of their loved one. They are invited to a coffee morning and any social event held at the home. The lounge has been redecorated and new sofas has been bought to encourage people to sit together in a less institutionalised manner. The service now have an Admiral nurse to assist in communicating with and supporting people with dementia and their relatives. The administration of medication has improved and staff training is on going. What the care home could do better: There is no requirement or recommendation from this visit however the registered manager must ensure that the service continues to provide a good standard of care. Key inspection report CARE HOMES FOR OLDER PEOPLE Selkirk Wing Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR5 2XL Lead Inspector Mohammad Peerbux Key Unannounced Inspection 16th June 2009 09:25 DS0000019120.V376067.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Selkirk Wing Address Woodcote Grove House Woodcote Park Meadow Hill Coulsdon CR5 2XL 020 8660 7656 020 8668 6411 manager@selkirk.fote.org.uk 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) Friends of the Elderly Ms Susan Guyon Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 20 16th June 2009 Date of last inspection Brief Description of the Service: Selkirk Wing is the nursing wing of Woodcote House and is situated in Coulsdon and owned by the registered charity Friends of the Elderly. It is registered by the Commission to provide nursing care for up to twenty elderly people. It is part of a large property set in secluded well-maintained grounds and surrounded by paddocks and woods. The grounds are over forty-five acres and include flowerbeds, lawns and patio areas. Adjacent to the home is a golf club with a clubhouse. The home is accessed by a private road and there is ample car parking. Accommodation is provided on the ground floor and communal facilities include a lounge with a dining area, hairdressing room and a chapel. The home is situated a few miles from local transport and shopping facilities. Selkirk Wing DS0000019120.V376067.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 two stars. This means the people who use this service experience good quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2009/2010. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. The registered manager facilitated this inspection. Some of the people were spoken to and they commented positively on the care they are receiving. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA).It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from the AQAA is included in the report. What the service does well: All new people receive a comprehensive needs assessment before admission. This is carried out by staff with skill and sensitivity. The home consults people using the service about their satisfaction with the service they are receiving. The home has a medication policy which is accessible to staff, medication records are up to date for each individual and medicines received, administered and disposed of are recorded. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet people needs. People who use the service are able to express their concerns, and have access to an effective complaints procedure, and are protected from abuse, and have their rights protected. The management and administration of the home is based on openness and respect, and has an effective quality assurance system. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No one is admitted into the home without a comprehensive assessment being undertaken. This means the home is aware of how people will need to be supported and can be confident that their healthcare needs can be met. EVIDENCE: Before agreeing admission the service carefully considers the needs assessment for each prospective person and the capacity of the home to meet their needs. They are given the opportunity to spend time in the home. Individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individuals agreement, carer’s interests are taken into account. The assessments are now being dated as recommended at the last inspection. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 9 Intermediate care for rehabilitation and return to the community is not provided by this home. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s care plans include detailed information about their needs and personal goals. This helps staff to know the individual’s needs and how to meet them. Overall the arrangement for health care needs of the person is good and they receive personal support in the way they prefer. EVIDENCE: Four people’s care plans were sampled at random and it was noted they generally included information necessary to deliver the persons care needs. The care plan is a working document reviewed regularly. Reviews focus on asking what has worked for the individual, where there are progress, achievements, concerns and identifies action points. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 11 It was positively noted that the home actively promotes a person’s right of access to the health and remedial services that they need, both within the home and in the community. The home has a medication policy which is accessible to staff, medication records are up to date for each individual and medicines received, administered and disposed of are recorded. There has been improvement made with regards to administration of medication in line with two requirements made at the last inspection. The home works creatively and actively with other services and organisations to ensure that the persons whole life needs are met, and goals addressed. The service recognises its own limitations and when to seek support from others to meet the individual needs of people. Observation of the staff team interacting with people that live in the home showed that the carers were mindful how they addressed individuals, and they were seen to be polite and friendly. People who were spoken to stated that they are happy with the way that the staff delivers their care. The service has recently completed the accreditation process for the Gold Standards Framework in end of life care and uses advanced care plans and priorities of care. All of the people complete an advanced care plan where their views on their end of life care are recorded and respected. The Commission recognises the good work that goes into achieving this standard and the hard work of management and staff. There is now a plaque at the service stating “This home has been awarded the Gold Standards Framework Care Homes Association Award for the high quality of care provided for people in the final years of life”. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home tries to be flexible and attempts to provide a service, which is as individual as possible. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to support people to develop their skills, including social, emotional, communication, and independent living skills. People using the service are given the opportunity to take part in a variety of activities both within the home and in the community. Following feedback from people using the service the home has introduced fortnightly musical therapy sessions which have proved to be both stimulating and enjoyable for many individuals. People who live in the home are encouraged to continue with their outside interests i.e Townswomens Guild and church groups. There is a chapel where an ecumenical service is held every Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 13 Thursday and Sunday. Those people who cannot attend and who wish to receive communion can do so in their rooms. The chapel has a loop system for individuals who are hearing impaired. People who use the service have the opportunity to develop and maintain important personal and family relationships. The home has open visiting arrangements and individuals know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. Snacks and treats are provided every afternoon in order that the people who eat very little can help themselves to food, this has proved very successful. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to an effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The home has an open culture that allows people to express their views and concerns in a safe and understanding environment. The service has a complaints procedure that is clearly written and easy to understand. Unless there are exceptional circumstances the service always responds within the agreed timescale. There is a general comments book and a food comments book located in the entrance hall, where people that live in the home, relatives and any other visitors can make comments about the service. There are policies and procedures for safeguarding people who use the service. The manager stated that most of the staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Staff working at the service know when incidents need external input and who to refer the incident to. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the individual’s health and emotional wellbeing. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet their needs. People who live in the home are encouraged to personalise their bedrooms. There is a selection of communal areas both inside and outside of the home, Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 16 this means that people using the service have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. All areas of the home are wheelchair accessible and there is moving and handling equipment to ensure that all areas of the home are accessible to everyone. Individuals are encouraged to use the patio area and assist the activities co ordinator to plant,water and maintain the garden. The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for residents. There is enough qualified and experienced staff to meet the health and welfare of people using the service. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Two staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 18 The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements. The manager is aware that there are some gaps in the training programme and plans to deal with this. The service is also able to recognise when additional training is needed. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides guidance and direction to staff to ensure individuals receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the person. EVIDENCE: The manager has the required qualifications and experience to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. She is currently undertaking a BSc in Professional Practice, palliative Care for the Older Person and is also the Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 20 link nurse for palliative care and facilitator for the Gold Standards Framework (GSF). Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The annual quality assurance assessment (AQAA) was received on time and contains clear and relevant information. The AQAA lets us know about changes the home has made and where they still need to make improvements. It shows clearly how they are going to do this. The regional manager visits regularly and at her Regulation 26 visit she always speaks to a selection of people and relatives and this give them a chance to comment on the service. The manager and activities coordinator hold regular meetings with the people using the service and their relatives. There is also a yearly quality audit where questionnaires are distributed to relatives and people that live in the home. The results of these questionnaires contributes to the overall quality mark. The home keeps a small amount of money in separate envelopes for each person with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. Certificates relating to health and safety were up to date servicing certificates. These included gas safety, fire safety and portable appliance test. The security at the entrance of the home has been improved to ensure the safety of people and staff. This is in line with a requirement made at the last inspection. Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 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 3 3 X X X 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 3 X 3 X 3 X X 3 Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 Selkirk Wing DS0000019120.V376067.R01.S.doc Version 5.2 Page 23 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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