Inspection on 20/10/06 for The Wren

This inspection was carried out on 20th October 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Wren 02/04/09

The Wren 02/04/08

The Wren 24/04/07

The Wren 03/03/06

The Wren 23/08/05

The Wren 06/02/05

The Wren 22/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 The Wren 92 Carlton Road Whalley Range Manchester M16 8BE Lead Inspector Sarah Oldham Key Unannounced Inspection 20 & 25th October 2006 09:00 th The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Wren Address 92 Carlton Road Whalley Range Manchester M16 8BE 0161 881 8658 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) Mrs Margaret Monteith Mrs Margaret Monteith Miss Dorna Monteith Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: The Wren is a care home providing personal care for a maximum of 8 people with learning disabilities who may also have a physical / sensory disability. The Wren is a detached property set within its own grounds. The home is three storey with a basement area used for offices, storage and laundry facilities. The residents’ bedrooms are on the ground and first floor. All the bedrooms are single; three of the rooms have shower facilities. There is a kitchen and dining room on the ground floor with a lounge situated on the first floor. There is a small lounge area situated on the first floor for the use of relatives of residents when visiting. This enables the resident and their relatives to spend time together in privacy if required. There are toilets and bathrooms situated on both the ground and first floor. These are accessible and meet the identified needs of the residents. The home is situated in a residential area in Whalley Range within easy reach of public transport links into Manchester City Centre. The home is a family run business. The fees for the home are from £800 - £900 per week. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place on Friday 20 October and Wednesday 25 2006. The visit formed part of the key inspection of the home and was undertaken by two inspectors who were at the home for 8 hours. As part of the visit time was spent with the residents who live at the home, observing how staff support the residents, discussions with staff and the manager, assessing relevant documents and files and a tour of the premises was undertaken. Some supporting evidence within this report was based on information received in the pre-inspection questionnaire that was submitted to Commission for Social Care Inspection (CSCI) prior to this visit taking place. What the service does well: What has improved since the last inspection? The home had purchased a professional management support system to enable them to develop the service. Care plans for residents had been developed and this was ongoing. Some refurbishment to the home had been undertaken including the bathrooms and some new furnishings to resident’s rooms. The home had arranged a holiday for the residents during the summer and this had been successful. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 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. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their family/representative are provided with information about the home to ensure that the home can meet their needs. EVIDENCE: All new residents admitted to the home had a care management assessment that identified their needs. The assessment included details about an individual’s physical, social, educational, cultural and emotional needs. The manager ensured that in completing the assessment it was identified if the home was able to meet the needs of the prospective resident. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident had an individual plan of care. However, some areas of the plan required improvements to ensure residents’ health, personal and social care needs were fully met. EVIDENCE: Since the last inspection the home had further developed the care plan. Details about individuals needs were recorded and then how the home planned to meet those needs. The home developed with the resident and/or their representative a care plan detailing how their identified needs would be met. As part of the inspection process four residents’ care plans were examined. Since the last inspection the home had developed care plans for the residents’ using a new care plan format The home used the care management assessment to form the basis of the resident’s care plan within the home. The details on two of the care plans examined required further development to include detailed risk assessments. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 10 The manager demonstrated that risk assessments had been completed but these were maintained separately to the care plans to enable staff to have access to them in an emergency. They had also been recorded on different documentation. It was discussed with the manager the importance of maintaining all documentation relating to an individual’s care needs together and to use the same format to ensure that the resident had a comprehensive risk assessment in place. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home cannot show fully that it offers and supports people to participate in activities within the house and in the community that they enjoy. Visitors are welcome and the routines of the home are based on peoples’ own preferences and activities. Meals are based on peoples’ needs and choices and appear nutritionally balanced. EVIDENCE: Most of the residents living at the home attended day care facilities provided by the local authority. For those days that that they did not attend, staff supported residents to access the local community. Details recorded on individual care plans did not detail clearly all activities that were made available or that were undertaken. The manager said that during the summer holidays the residents had been on a holiday, which appeared to have been successful. The home also arranged various activities within the community. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 12 Family and friends were welcomed to the home and were able to spend time with the resident either in private or within the communal areas of the home. Staff members were observed to treat the residents with dignity and respect and interacted with residents in an appropriate way. Mealtimes at the home were planned and not rushed. There was evidence that a wide variety of food was available and residents were offered a variety of nutritious and balanced meals. Those residents who required assistance at mealtime with eating and drinking were supported appropriately and equipment to assist with eating and drinking was available. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident had an individual plan of care. However, some areas of the plan required improvements to ensure residents’ health, personal and social care needs are fully met. EVIDENCE: Residents’ were supported with their personal care in the privacy of their own bedroom. Staff were observed to treat residents with dignity and respect. The individual support needs of residents’ were detailed in their care plans although the level of recording varied and it was identified that some care plans required more specific details. This was discussed with the manager during the visit to the home. The health care needs of the residents were recorded and where there was an involvement of health care professionals this was recorded on the individual resident’s file. Two files examined contained comprehensive details about managing and monitoring specific health care needs, these were accessible to all staff providing care and support to the residents. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 14 At the time of the visit to the home the manager said that none of the residents were able to manage their own medication although there was no risk assessments undertaken regarding this. Records were maintained of all medication that was prescribed and Medication Administration Record (MAR) sheets were completed by senior staff responsible for administering medication. The home was in the process of changing the pharmacy that delivered medication and the new pharmacist planned medication training for staff. Medication was stored in lockable cabinets secured to the wall within a lockable room. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had limited systems and procedures in place that allowed people to express their complaints and concerns however, residents were not fully protected from abuse. EVIDENCE: The home had a policy and procedure in place for the Protection of Vulnerable Adults. Staff had not received Protection of Vulnerable Adults (POVA) training – this was due to courses for the said training being cancelled and limited places available. Staff had not had any form of training provided by the management regarding POVA. Staff spoken to were unclear about the policy in place and what they should do in the event of an allegation being made. The manager said that there was a complaints book in place where complaints were recorded. The manager said that there had been two complaints received but the Commissioning Unit for Manchester City Council had addressed these. The complaint book was not available at the time of the visit to the home and therefore the inspectors were unable to examine this. It was discussed with the manager the importance of maintaining appropriate documentation that was available for inspection purposes. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decoration in most areas of the home provided a comfortable and welcoming environment. However, some areas that required redecoration/ refurbishment. EVIDENCE: Since the last inspection in March 2006 some areas of the home had been redecorated, these included the bathrooms and toilets. Residents own bedrooms and the communal areas had not been redecorated although there was evidence that some bedrooms had new furniture and fittings. Lounges had new curtains fitted. There were general signs of wear and tear appearing throughout the building in particular to the paintwork and some of the soft furnishings required repainting and renewing. The manager indicated that there were plans to repaint the building within the coming months. The inspectors discussed with the manager that it was important that the home had a planned maintenance and refurbishment programme in place to The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 17 ensure that the residents lived in a clean, comfortable and homely environment. The home was found to be generally clean throughout. The carpets were beginning to show signs of wear and tear, although they were cleaned on a regular basis. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff available appeared sufficient to meet the residents’ assessed needs. However, the procedures for recruiting staff did not provide adequate safeguards to protect residents. EVIDENCE: Staff spoken to were able to demonstrate an understanding of the needs of the residents’ at the home and appropriate interaction between some staff and residents was observed. There was no evidence that specific therapeutic or rehabilitation programmes were undertaken within the home. The residents had complex needs which the staff appeared to have an understanding of and were able to provide support to individual residents who were unable to verbally communicate their needs. Some staff at the home had undertaken National Vocational Qualification (NVQ) Level ll and the manager said that further staff had been identified to commence the NVQ Level ll training. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 19 Staff training and development files were not in place and training for staff had not been recorded or documented. Some files contained information about training that had been undertaken by some staff but not all. Some staff files had evidence of induction but this was not available on all files viewed. On the days of the visits to the home and examination of the staffing rota there appeared to be the appropriate numbers of staff on duty. The manager said that staffing levels would be reviewed if there were a change in the residents’ needs. Some of the residents’ received support within the home from health professionals within the community and this was recorded on individual resident care plans. The manager said that regular staff meetings took place however, records of these meetings were not made available during the visit to the home. The manager said that every day there was a hand over meeting to ensure that staff were aware of any change in the residents’ needs. These meetings were not documented. It was discussed with the manager the importance of maintaining records of staff meetings to ensure that staff received the necessary information and support to undertake their role. Four staff files were examined. They did not contain all information required in accordance with Schedule 2 of the Care Home Regulations 2002. Some files viewed did not have the appropriate Criminal Records Bureau (CRB) disclosure in place. This could place residents at risk if staff have been recruited without the appropriate statutory checks being undertaken. Staff files were maintained in loose-leaf folders and paperwork was not secured. All staff had terms and conditions of employment in place. It was discussed with the manager the importance of ensuring that staff files contained information in accordance with Schedule 2 of the Care Home Regulations 2002. The manager said that staff received supervision on a regular basis, however this was not routinely recorded. Staff spoken to said that they received support and supervision from the manager and generally felt that they were supported well within their role. They did not however, receive minutes of supervision. It is important that staff receive supervision and guidance that is clearly documented to ensure that they are aware of the aims and objectives of the home in supporting residents with complex needs and their role within this. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had appropriate management procedures in place to ensure the health and safety of the residents’. EVIDENCE: The home had two registered managers in post. One of the managers was undertaking the NVQ Level IV. Both managers have a number of years experience working within a care home. The home had policies and procedures in place and the home had recently purchased a professional management support system to enable them to further develop the service. The manager had commenced using the system and was in the process of ensuring that the home used the documentation to enhance the service The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 21 provided. At the time of visiting the home it was noted that although the manager had commenced using the new documentation the manager was also using old documentation. It is important that the home uses consistent documentation to ensure a continuity of care and support for the residents within the home. The management support system had documentation to undertake quality monitoring and the manager said that they would be using the documentation to gain the views of the residents, family, friends and relevant health care professionals regarding whether the home was providing appropriate support for the residents. Evidence was seen that regular health and safety procedures were undertaken within the home including fire safety training, regular fire alarms and emergency lighting testing and the maintenance of fire precaution equipment. The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Care plans must continue to be developed to ensure all the needs of the residents’ are recorded clearly. Each member of staff must have an assessment of their training needs carried out. (Previous timescale of 1 June 2005 and 30/06/06 not met) The home must operate a robust recruitment process and obtain two written references for all new staff in order to protect residents.(previous timescale of 30/06/06 not met) Timescale for action 30/01/07 2 YA33 18 30/01/07 3. YA34 18 30/01/07 4. YA35 18 A training and development plan, 30/01/07 linked to the homes aims and objectives and service users needs must be implemented (Previous timescale of the 1 June 2005 not met). The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 24 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 YA35 Good Practice Recommendations It is strongly recommended that the home maintain a comprehensive staff file for each individual member of staff containing information regarding recruitment and selection, staff training, staff supervision in addition to the information required under Schedule 2 of the Care Home Regulations 2002. The Service Users Guide must be in a clear and accessible format for all residents (Previous timescales of the 1 June 2005 and 30/07/06not met). The home must have a planned maintenance and renewal programme for the fabric and redecoration of the premises (Previous timescale of the 1 June 2005 and 30/06/07 not met) A quality assurance format must be developed to gain the wishes and views of the residents within the home 2 YA1 3 YA24 4 YA39 The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 The Wren DS0000021630.V301416.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!