Inspection on 08/07/09 for Belong Wigan

This is the latest available inspection report for this service, carried out on 8th July 2009.

CQC found this care home to be providing an Excellent 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.

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Belong Wigan Millers Lane Platt Bridge Wigan WN2 5DD Lead Inspector Judith Stanley Key Unannounced Inspection 8th July 2009 09:30 DS0000073238.V377321.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. Belong Wigan DS0000073238.V377321.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 Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belong Wigan Address Millers Lane Platt Bridge Wigan WN2 5DD 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) 01942 855600 www.clsgroup.org.uk CLS Care Services Limited Mrs Sarah Sephton Care Home 66 Category(ies) of Dementia (66), Old age, not falling within any registration, with number other category (66) of places Belong Wigan DS0000073238.V377321.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 - Code N. To service users of the following gender: Either Old age, not falling within any other category - Code OP. Dementia - Code DE. The maximum number of service users who can be accommodated is: 66. Date of last inspection New Service Brief Description of the Service: The Belong Village is owned by CLS services and offers care for 66 residents. There are six separate households, each able to accommodate 11 people requiring different types of specialist support. The village has been built in the grounds of Sherwood House (CLS) and most of the staff and residents transferred over in to Belong in February 2009. The village has been built in the centre of the community and is surrounded by local shops and other amenities. Belong is a purpose built village that offers excellent accommodation, all bedrooms have en suite facilities and rooms were tastefully decorated. Each household has a lounge and dining area, television and music system, a fully fitted kitchen, laundry facilities and a sun terrace. Bathrooms and toilets are situated in close proximity to communal areas. There is a guest suite for relatives and friends to allow them to stay if required. Belong has a Beauty and Barber salon which is open six days a week. There is a Bistro where residents have the choice to dine and invite family members for a meal if they wish, a gym, internet café, the village shop for essentials and gifts and The Venue with surround sound cinema facilities and a licensed bar and dance area. These areas are open to the public; however the households are private and only accessible to residents and their visitors. Outside garden space is available with tables and chairs and sunshades on the terrace outside the Bistro. Car parking is available within the village grounds Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 5 and it is permissible to park on the road. The current scale of fees ranges from £550:00 to £700:00 depending on the type of care required. Additional charges are made for hairdressing and beauty treatments, purchasing goods from the shops and dining in the Bistro. For residents who prefer to eat in the Bistro and not in the households they have the choice to do so at no extra charge as their meals are included in the fee charged. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was the first inspection of this service. The visit was unannounced and lasted for 6 ½ hours. A pharmacist inspector from the Care Quality Commission (CQC) also visited the village to check on the medication systems. Part of the time was spent looking at information the home holds on residents (life plans or care plans) and other records the home needs to keep to ensure that the home is being properly run. During the course of the day we spoke with the managers, staff and residents. Some weeks before our planned visit the manager was asked to fill in a self assessment form, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they could improve upon. This helps us to determine if the management of the home sees the service they provide the same way that we do. We felt the AQAA was filled in honestly and that a lot of time and effort had been given to filling it in. To find out more about Belong we asked residents and staff to complete our surveys. We received feedback from eight residents and seven staff. Residents indicated that they were happy at the home. One resident said, “The home provides high standards of care and treats residents as individuals”. Another said, “I am very happy with the care I receive, the home is well managed, with the focus always on what is best for the residents. The staff are caring, I enjoy the food and the various activities provided. The hairdresser is excellent and I like to eat in the Bistro when people visit”. Staff comments were positive. One said, “This is a fantastic place to work, we provide residents with a ‘home’ enhancing quality of life in a relaxed and caring environment”. Another said, “The care and facilities are excellent and we have a great staff team”. What the service does well: Belong is a well managed and well run home ensuring a high standard of care for the people living there. Belong encourages and welcomes members from the local community to visit and use the facilities available. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 7 Residents have access to everything they might need to live a comfortable life. If something is needed, relevant to a person’s health and well being, arrangements are made for it to be obtained. The premises are of an excellent standard; each area is tastefully decorated, furnished and well equipped. Most of the staff and residents transferred over from Sherwood House to Belong so relationships and friendships had been maintained and residents were familiar with the staff. Staff were well trained and show commitment towards giving good care to residents. Records are kept to a good standard; some information is in the process of being transferred on to the homes data base. The office was well organised and everything was easily accessible. The service is not complacent and is constantly looking for ways to improve for example further development to the outside areas. 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. Belong Wigan DS0000073238.V377321.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 Belong Wigan DS0000073238.V377321.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 were assessed. Standard 6 does not apply as the village does not offer an intermediate care service. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People thinking of moving into the village received sufficient information to help them to make their decision that this is the right place for them to live. Detailed assessments make sure people’s needs and personal aspirations are assessed and responded to appropriately. EVIDENCE: The home has a statement of purpose and a service user guide. This information informs people about what goes on in the village and the facilities available to them and what people can expect if they decide to move in. The information also tells people about the management of the home and the Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 10 staffing structure. Information was available to prospective residents and a copy was seen in resident’s private accommodation. There is also a colour brochure in the reception area which provides details about the Belong village such as the main values of living at Belong, what the households are like and how they are equipped and about the village facilities. The village has its own website and a DVD is also available. We spoke with the administrator about residents contracts. There was evidence to show that residents were in receipt of a contract/statement of terms and conditions and feedback on completed surveys indicated that residents had a contract. The homes date base is currently being updated and contracts were being imputed on to resident’s information folders. We were shown examples of how this works. Prior to any prospective resident moving into the village a full assessment of their needs is carried out by a member of the management team or by a qualified nurse. This is a detailed assessment procedure to ensure that the home and staff can fully meet the individuals care and social needs. We selected six residents life plans to work with, one from each household. All had an admission assessment in place. The assessment covers personal details such as next of kin, friends and relatives address book, preferred term of address and name and address of current doctor etc. Other information included, residents well being, all areas of risk including history of falls, mobility, toileting, bathing, dressing, personal care, oral care, foot care, nutritional status, medication, likes and dislikes and general activities. Two of the households provide care for people with a dementia related illness. Staff had undertaken training in this specialised area of care and had the necessary skills and experience to deliver the care which the village offers to provide. All six households have clearly defined sections, good signage and prompts and good use of colour contrast and texture to aid recognition. Prospective residents and their relatives are encouraged to visit the village and assess the quality of the facilities and suitability of the service. People are encouraged to spend the day or a short stay over night, have a meal and meet other residents and staff. The home offers a guest suite if people wish to stay with relatives. Belong Wigan DS0000073238.V377321.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 were assessed. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Belong are involved with the development of their individual life plans so they receive the care and support they need in the way they prefer. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy were put into practice so people living at the Belong can be confident they will be well cared for. EVIDENCE: We continued to use the same six life plans selected. The information contained in the life plans gave staff detailed information about the care each resident required. The life plans were compiled with the resident/relative and care professionals being involved in the process. Life plans were written with a Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 12 person centred approach for example, my health needs are, I need you to help me with, I will need you to get my medication from the chemist and I require constant reassurance and supervision etc. Other areas of care include: food and drink, communication, getting ready for the day, toileting, skin and hair care, getting out and about, comfort and relaxation, occupying my day, sleep patterns, emotions and end of life wishes. All life plans are kept in the residents own rooms and are available for residents, relatives and other health care professionals to view as agreed by the resident. Each resident has a daily diary in their room and nursing residents have a nursing progress sheets as well. Residents and relatives are encouraged to write any comments or feelings in their diary. Other information in the life plans included risk assessments for example risk of falls and mobility, moving and handling and nutrition. Food and fluid charts were being used to monitor some resident’s food and fluid intake; these were seen to be completed as required. Risk assessments for managing pressure care were seen in some resident’s files and turning charts and equipment used was documented and the charts had been appropriately completed. A social profile was seen in the life plans; this is completed by residents or their relative. It provides staff with information and generates topics of conversation about the resident’s life experiences for example where they were born, school days, their wedding day, hobbies and interests etc. The life plans also contains a photograph album of resident’s favourite photographs. There was evidence to demonstrate in the care plans that outside agencies are contacted such as people from the falls prevention service, the dietician, chiropodist and doctors. All medical treatment is supported in the residents own room or in the Belong surgery. Staff were in the process of building relations with the Steps to Health team. The team will be supporting residents at the village and in the outside community. The life plans had been reviewed as required and any changes in residents care needs were clearly identified. We looked at how peoples medicines were handled and found that suitable arrangements were in place. Medicines policies and procedures provided written guidance to staff in the handling of medicines at the home and staff had completed certificated training in the safe handling of medication. Checks had been made to ensure that staff were able to handle medicines safely. Records for the receipt, administration and disposal of medication were good and there were few gaps in information. This meant that on the whole the treatment received by people was clear. We checked a sample of medicines and records to make sure that medicines could be accounted for and to show that they were administered correctly. Whilst the majority of these samples were in order, there were a few minor discrepancies but we had evidence to Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 13 show that the manager regularly audits (checks) medication and this has enabled matters to be highlighted and addressed. Records showing the administration of medication were generally up-to-date but there were some areas that could be improved to ensure the completeness and clarity of these records: where medicines have been given late or not been given at all, the reasons for this must be clearly recorded. We found that all medicines including controlled drugs (powerful medicines) were stored securely. This helps to ensure that they are not misused or mishandled. People had their own personal cupboard where their medicines and records were stored. Medicines were generally administered in peoples private rooms at a time of their choice. This promotes privacy and dignity for people using this service. We saw one example where a persons medicines had been overlooked as they had woken late and we gave advice as to how the service could safeguard against missing doses in this situation. Care was taken to complete the records immediately after administration to help ensure they are accurately maintained, reducing the risk of mistakes. Patient support was offered where people needed help when taking their medicines. The home has made arrangements so that non-prescribed medicines for the treatment of minor ailments can be given. This benefits people at the service as they can receive treatment for conditions such as minor pain without delay and without the need to see the doctor. Where medicines were prescribed when required there was written information for staff about when that person may need the medication, but this was not completed for everyone. Staff spoken with were knowledgeable about the use of these medicines written when required information should be completed and kept up-to-date to help ensure consistency in their use. Observation throughout the inspection showed that the personal care needs of the residents were being met. Attention had been given to personal grooming. The Beauty and Barbers salon is open six days a week, so that residents are not restricted to set days. Staff were heard speaking to people in a respectful and friendly manner. Each resident has a key worker. This is to promote privacy and dignity and to enable staff to gain trust between the residents and staff and the support worker. Where possible the same staff work in the same household to provide continuity of care and to try and ensure that personal care is offered on an individual basis by the same carer. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15 were assessed. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to make choices about their lifestyle and are helped to maintain their independence so life at Belong meets their expectations. Social activities and meals are well managed and provide daily variation and interest for people. EVIDENCE: Belong has an activities coordinator that works five days a week. With the help of the residents an activity programme is planned to cover a range of indoor and outdoor activities. The day before our visit some residents had been on a trip to Southport and some had been to the War Museum in Manchester. Other activities include shopping trips, arts and crafts, quizzes, games, dominoes and bingo. One returned residents surveys states, “I enjoy all the various activities, especially the dancing where I partner with a Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 15 gentleman from another household”. Films and DVDs are shown in The Venue which is equipped with a surround sound, cinema facilities and a licensed bar. On the day of our visit residents were holding a coffee afternoon in the Bistro to raise money for Marie Curie; members of the local community were also joining in and later took part in a quiz. Residents are encouraged to use the facilities including the Internet Café and can select books from the library and the Belong shop. The village has a range of pets including a cat, fish and birds which the residents enjoy and help to look after them. The village holds church services for those residents who wish to partake and welcomes people from the outside community to join in. Resident’s religious beliefs were documented in their life plan. Visitors are welcome to visit at any time, although it is appreciated if they avoid meal times in the households so that residents can enjoy their meals with the minimum of disruption. The Bistro is open where people can meet for a meal or have a drink together. The staff at Belong actively encourages and supports residents to make choices and decisions. Some residents go out of the home unaccompanied as is their choice. Some residents, with support like to carry out household chores such as clean their own rooms, helping prepare food, peeling vegetables and washing dishes etc. Some residents tend to their own personal care, such as showering and dressing and others require assistance, details of which are recorded in the life plans. Residents spoken with confirmed they got up when they wanted and went to bed when they were ready. Residents have the choice of where they wish to dine, some like to eat in their own rooms, some in the Bistro and others in the households dining area. Mealtimes are totally flexible, the households kitchens and fridges are stocked daily by staff and residents. Some residents (who have been risk assessed) are able to make a drink of their choice when they wish. It was noted that hot and cold drinks were readily available at all times. The meals at Belong are planned with help of the residents. There is a fully fitted kitchen on each household. This allows meals to be cooked by staff and residents. Residents have a choice of what they want to eat or they can go to the Bistro where alternatives are available. One resident said, “The choice of food is very good, from nice snacks to a full dinner”. Breakfast is served until late morning and residents are offered a range of dishes including; cereals, porridge, grapefruit, toast and preserves, a full English breakfast and tea or coffee or whatever they would like. At lunchtime a lighter meal is offered such as soup and sandwiches, jacket potatoes, salads etc. A range of deserts is available. The main meal is served in late afternoon, a choice of meals is available or residents can dine from the a la carte menu served in the Bistro. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 16 Where possible staff and residents sit and dine together to help make mealtimes a homely and sociable time and staff are able to assist if any resident needs help with their meal. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 17 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): 16 and 18 were assessed. 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. There are good procedures in place so people who live at Belong are able to express their concerns and know they will be listened to. Their rights are protected and they are safeguarded from abuse. EVIDENCE: A complaints procedure exists and records of complaints are kept and properly recorded. Belong encourages customer feedback and feedback forms are easily accessible. Residents who lack capacity can be supported via an advocate. Information on the AQAA tells us that there had been two complaints since the village opened. These had been suitably dealt with by the manager within the agreed timescale. There had been no complaints forwarded to the CQC. There have been no safeguarding issues regarding existing residents. However the manager acted promptly and efficiently when concerns were raised regarding two residents who came to live at Belong from another care home. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 18 All staff have had training in the protection of vulnerable adults on their induction and through the NVQ training. This is also readdressed in staff supervisions and appraisals. The home has a copy of the local councils’ adult safeguarding procedures, this is accessible to staff if needed. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 19 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): 19, 22, 24, and 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment at Belong is excellent making it homely, comfortable, clean and pleasant for residents to live in. EVIDENCE: The Belong village is a brand new purpose built building, comprising of six households each able to accommodate eleven people. Each household offers clearly defined sections, including a fully fitted kitchen and lounge/dining area. Each household has been tastefully decorated and furnished with modern, yet age appropriate fixtures and fittings. The living space leads out on to a patio or balcony area. We looked at several bedrooms and these were found to be Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 20 warm and comfortable, of a good size, with fitted furniture, good quality furnishings and a television. Every bedroom has a large en suite, with a wet room shower facility and appropriate grab rails etc. There are bathrooms and toilets available on the households. All rooms have an individual medication safe to enhance security, privacy and dignity. It was noted that most residents had personalised their rooms with their own mementoes and belongings brought with them from home. Residents have access to telephone calls either in their own room, main living room or via the pay phone in the reception area. Outside every bedroom there is a sensor which can be set to different settings, for example if a resident got up during the night this would alert staff. Bedrooms are fully heated with individual controls for choice and temperature control. As mentioned in the summary of the report the village has a range of services and venues that enhances the quality of life for residents and the local community. The outside of the home is well maintained and grounds were neat and tidy. There was a colourful array of plants and flowers. The terrace outside the Bistro has tables, chairs and sunshades so residents can sit out and enjoy the pleasant surroundings. Systems were in place to control the risk of cross infection. Staff wear protective clothing and gloves as required. The laundry is sited away from residents and laundry staff have an in and out door for dirty and clean laundry. The laundry was well equipped with washers and dryers and was very organised with individual baskets to ensure residents get their own laundry returned promptly. There is also a washer and dryer on each of the households for personal dignity and choice as some residents may want to wash personal items. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30 were assessed. 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 people living at Belong are well supported by well trained, effective staff that had been properly recruited, so people needs are met and they are safe from possible harm or poor practice. EVIDENCE: On the day of the inspection there were an adequate number of care staff working in the households. The ratios of care staff to residents takes into account the needs of the residents. Information on the AQAA tells us that the staffing team consists of the general manager, support manager, registered nurses including RGN and RMN, senior support workers, support workers, front of house manager, administration staff, receptionist, head house keeper, core domestics, domestics, head chef, cooks, Bistro staff, activity coordinator and a maintenance person. There are also four supernumerary support workers to cover annual leave and sickness. Most of the staff are qualified or working to NVQ level 2 or 3 in care. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 22 Most of the staff team transferred over from Sherwood House; however staffing numbers have now doubled. There are now ninety one female staff and two male staff working in and around the village. From discussions, staff showed they know the residents needs well and they demonstrated a strong commitment to providing a high standard of care. Staff were clear about the work they were employed to do and that they were happy to help each other out. One member of staff spoken with said, “I love my job and working in a place like this makes it even better”. From our observations, staff morale appeared good and the staff seemed genuinely happy to be working in the village. A full copy of each members of staff’s employment file is kept in the village in a secure location. We looked at four staff files and these were seen to be complete with, a written application form, two written references, Criminal Records Bureau check (CRB), job descriptions and other forms of identification such as copy of their passport and birth certificate etc. A list of current training was also available in the files along with supervision notes and appraisals. All new staff undertakes a full induction programme on commencement of work. Staff training is on going and staff were able to describe training courses and awareness sessions they had attended. Staff confirmed that the training offered was good and relevant to the work they do. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35 and 38 were assessed. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Belong was well run and a high level of consultation with people meant that people using the service could contribute to its development. The management and administration of Belong is based on openness and respect. This ensures that the home is run in the best interests of the people who live there. EVIDENCE: The manager was appointed before Belong opened and worked at Sherwood House with the then existing homes manager. The previous manager of Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 24 Sherwood House has been promoted to the village’s general manager and is there to oversee the running of the village and offer support as required to the support manager. The support manager has the necessary skills and experience to manage the village and the staff team. It was evident from our observations and through our discussions that the home is being well managed and that the support manager knew the residents and her staff team well. The support manager is committed to her own training and that of her staff team and sees this is an essential element to delivering a high standard of care for residents. To ensure staff can always ask for advice and support if needed a member of the management team is always on call. There are clear lines of accountability in the home which staff and residents are aware of. The way in which the home is run is open and transparent. The manager operates an ‘open door’ policy so she may be approached at any time by staff, residents or their families. The staff use a variety of methods to seek the views of the people living at the village. This includes residents and relatives meetings, one to one chats, the use of an advocacy service, satisfaction questionnaires and a comments book is available in each of the household. Regular audits are carried out through the villages own quality assurance system and includes medication, life plans, falls and accidents that may have occurred etc. A written report is completed by senior management who visit the village at least monthly and report their findings. These reports were available for inspection. The staff will also take in to account comments, ideas and suggestions from the local community. The office is very well organised so that staff have access to all the paperwork they might need during a shift. There are additional systems in place to check that everything is recorded when it should be and kept up to date. Records kept and required by regulation were seen to be in good order and up to date, all records are kept securely as required. Policies and procedures had been developed that are based on providing the highest quality of care and accommodation. These are reviewed regularly and revised as required. A system had been introduced where residents have a payment card (similar to a switch card). The card can be topped up and residents use their card to pay for meals in the Bistro, hair and beauty salon and items from the village shop. Residents therefore do not have to worry about carrying money or where it is being kept. Information is stored on the village computer. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 25 Prior to registration the home is subject to health and safety checks and certificates for equipment must be approved. All the necessary checks were completed in January 2009, these included: the electrical circuits, portable appliance equipment, the lift, hoists, fire detection and alarm, emergency lighting, emergency call equipment, heating system, soiled waste disposal and gas appliances. Safety notices are posted to alert staff to possible hazards. Those aimed at residents take in to account communication needs Any accidents, injuries or incidents are recorded properly and reported. The CQC are informed as necessary. The support manager works well with the CQC and informs us of any events, which may occur and manages any problems arising in a professional manner. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 26 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 4 3 4 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x 4 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 4 x 4 x x 3 Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 27 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. 1 Refer to Standard OP9 Good Practice Recommendations Ensure reasons for late administration or omission of medicines are clearly documented. Risk assessments should be completed where this is a regular occurrence. Belong Wigan DS0000073238.V377321.R01.S.doc Version 5.2 Page 28 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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). 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. 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