Inspection on 23/08/05 for The Wren

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

The Wren 02/04/09

The Wren 02/04/08

The Wren 24/04/07

The Wren 20/10/06

The Wren 03/03/06

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 Sue Jennings Unannounced 23 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 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 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 Montaith Mrs Margaret Montaith CRH Care home PC Care home only 8 8 Category(ies) of LD Learning disability registration, with number of places The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06 February 2005 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 newly built 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 Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during a 6.5-hour period on the 23rd August 2005. During the inspection, time was spent talking with staff members and the registered manager. In addition, a sample of people’s files, records and other relevant documentation were examined. At the last inspection the home needed to work on several areas to make sure it met the National Minimum Standards (NMS). A number of these improvements had been completed but some areas remained outstanding. In the last 12 months the Commission for Social Care Inspection has received no complaints regarding this service in relation to the living conditions at the home. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: Residents are admitted to the home following a Care Managers Assessment. The home also undertakes a pre-admission assessment to ensure that the home can meet all of their needs. The home’s décor was in need of some attention. Furniture and the facilities at the home are of an acceptable standard. A variety of communal areas are available for the residents. The atmosphere in the home was warm and welcoming. Staff were observed to be pleasant and courteous. Staff were seen to have good interactions with residents. The home supports people with learning disabilities who may also have physical disabilities. Residents had help to maintain their general and mental health the home supports residents to gain access to both general and specialist healthcare such as occupational therapists, speech and language therapists, psychiatrists and psychologists. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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 F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 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 standard(s) 1 and 2 On arrival residents are provided with information about the home and its services and their needs are assessed and identified. EVIDENCE: The manager reported that the Service User’s Guide was still under review and the home was in discussions with other professionals in order to develop a pictorial user-friendly document. New residents admitted to the home had an assessment undertaken by a care manager. The manager stated that the home worked in conjunction with the care manager, resident and their representative to ensure that a full assessment had been undertaken prior to the resident moving into the home. The home’s own in-house assessment was undertaken within 24-hours of the person’s arrival. The assessments were detailed and clear and identified the person’s priority needs and goals. Evidence was also seen of specialist health and behavioural assessments. The home sometimes admitted residents in an emergency situation and the manager stated that relevant information would be requested within 48-hours of admission. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 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 standard(s) 6 and 9 The home clearly identified resident’s needs and goals and had identified situations and personal behaviours that may place them at risk. EVIDENCE: The home develops comprehensive care plans from the assessments of resident’s need that cover aspects of personal, social and healthcare needs. Care plans identify resident’s goals and the support the home provides to meet those goals. Each resident had an individual care plan that had been developed in conjunction with the Care Management assessment and their representative. Care plans contained details of all personal care needs, likes and dislikes, plans of daily activities and any specialist involvement, for example physiotherapy, day service provision etc. Residents were unable to make informed decisions regarding risk taking due to their complex needs. The manager and staff assessed risks on a day-to-day basis involving relatives and advocates. Risk assessments and care plans were reviewed on a regular basis according to the complexity of the support and level of a resident’s needs. Each resident’s care plan had a photograph and an emergency contact sheet. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 10 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 standard(s) 12 and 13 Residents receive the opportunities and support to participate in appropriate activities within the home and in the local community. EVIDENCE: The residents accommodated at the home attended various day service provisions run by the local authority. Residents attended different day service provision on different days. There was evidence that there was good communication between the day services and the home. Some of the people who live at the home were registered with the Ring and Ride Service. When not attending day care the residents were supported by staff to access the local community i.e. shops, library, leisure centre etc. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 11 The manager stated that whenever possible trips were arranged to ensure that residents had the opportunity to participate in activities within the community to promote the principle of ordinary living. The home supported residents on a one-to-one and group basis to access community social and leisure activities such as shopping, meals out and day trips. On a regular basis residents accessed the local shops with the support of staff. The manager stated that one of the favourite outings to both McDonalds and to Manchester Airport for meals. As well as the meal at the Airport the residents were able to watch the aircraft take off and land. The manager reported that the menu was based on a two-week rota but was flexible. There was a choice of porridge or cereal or a cooked breakfast. The manager said that the menu contained a lot of fresh vegetables and that the home had an allotment and grew a lot of the vegetables used and all meals were prepared fresh on the day. Ten staff members had successfully completed the Basic Food Hygiene course. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 12 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 standard(s) 18 and 19 The home encourages and supports residents to maintain their personal, emotional and healthcare needs. EVIDENCE: The manager stated that personal care support was undertaken with dignity and respect. Everyone accommodated at the home had his/her own rooms with hand washbasins. People living at the home were supported in choosing their own clothing each day this was achieved by staff showing a variety of clothing and the person pointing to the clothes they wanted to wear that day. However, it was reported that staff members were aware of individual residents likes and dislikes with regards colours and clothing. The manager ensured that access to specialist support and advice was made available. This was evidenced by documentation in the resident’s personal file. Each resident was registered with a local General Practitioner and details of appointments were held on their file. Where a resident has a hospital appointment a member of staff would accompany and stay with them. This was evidenced on the day of inspection when a member of staff came on duty to escort a resident to the hospital. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 13 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 standard(s) 22 and 23 Residents are provided with the opportunity to raise their views and concerns and the home has the policies, procedures and systems in place to protect people from harm. EVIDENCE: The home had a complaints procedure and a copy had been given to each resident in a ‘welcome pack’. The home had policies and procedures relating to abuse/protection of vulnerable adults, a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse in line with the Department of Health No Secrets guidance. The home had a ‘Whistle Blowing’ policy. The manager was aware of the procedures to be followed in the event of an allegation of abuse. Staff training on protection of vulnerable adults had not formally been undertaken although some staff had received training as part of the NVQ level II award. The manager was aware that this training should be ongoing and take account of any changes in legislation. The manager was aware of the need to protect residents living in the home by obtaining a Criminal Records Bureau check and checking all new staff against the Protection Of Vulnerable Adults list. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 14 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 standard(s) 24 The standard of decoration in the home provided a comfortable and welcoming environment. EVIDENCE: The home appeared to be suitable and safe for the residents accommodated. The stairs had been fitted with gates in keeping with the household décor to reduce the risk of residents accessing the stairs without support of a member of staff. The home had a passenger lift for residents living in the home. The home had been built in 2001 and had adhered to all planning regulations for a care home. The paintwork in communal areas was beginning to show some signs of general wear and tear. The requirement made at the last inspection that a maintenance plan be developed to include planned maintenance and renewal programme for the fabric and decoration of the premises, is reiterated in this report. The remaining standards in this section will be fully examined at the next inspection. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 The numbers and skill mix of staff were sufficient to meet the needs of the people accommodated. The homes recruitment policies and procedures promoted the safety and wellbeing of the residents although an area of concern regarding taking up references was identified. EVIDENCE: A random sample of staff files were examined during the inspection and found to contain only one written reference, which in two cases were poor. The manager must ensure that two written references are obtained and any concerns raised about a reference followed up with a phone call to the referee to discuss the contents. Each member of staff must have an assessment of their training needs and a training and development plan, linked to the home’s aims and objectives and resident’s needs must be implemented. The requirement made at the last inspection is reiterated in this report. Staff members files examined were found to contain evidence of Criminal Record Bureau checks, application forms, proof of identity, induction schedules The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 16 and photographs of individual staff. However, there was little documentary evidence on staff files to show that they were receiving regular recorded supervision. A record of supervision sessions was not being made. The requirement that each member of staff receives formal recorded supervision is reiterated in this report. The manager reported that all staff members were appraised at the end of their three-month probationary period. Appraisals would then take place every six months. The manager stated that training was made available to all members of staff. A number of staff had completed NVQ Level II training. The requirement made at the last inspection that a formal training plan must be developed to ensure that training is undertaken and updated at the required intervals remained outstanding and the requirement has been reiterated in this report. The manager reported that on the job supervision was carried out and that if there is an issue with a member of staff’s work practice this would be dealt with immediately however, this was not usually recorded. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The home had the policies, procedures and systems in place to maintain the health and safety of people living at the home. EVIDENCE: All staff had completed Health and Safety training. Most staff had completed training in basic food hygiene, moving and handling and first aid training. Evidence was seen that gas and fixed electric appliances were serviced on an annual basis. The manager reported that a Portable Appliance Test had been carried out. However, a Portable Appliance Test certificate was not available for inspection and the manager should make arrangements for a copy to be forwarded to the Commission for Social care Inspection. Fire drills, training and tests were undertaken on a regular basis. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 18 Records for periodical health and safety checks were current. Risk assessments and data sheets for the Control of Substances Hazardous to Health had been undertaken. The Wren F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Wren Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement The Service User’s Guide must be in a clear and accessible format for all residents (Previous timescale of the 1 June 2005 not 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 not met) Each member of staff must have an assessment of their training needs carried out. (Previous timescale of 1 June 2005 not met) The home must operate a robust recruitment process and obtain two written references for all new staff in order to protect residents. Timescale for action 30.9.05 2. 24 16 30.9.05 3. 33 18 30.9.05 4. 34 18 30.9.05 5. 35 18 A training and development plan, 30.9.05 linked to the home’s aims and objectives and service users’ needs must be implemented (Previous timescale of the 1 June 2005 not met). F55 F05 s21630 wren v244552 230805 stage 4.doc Version 1.40 Page 21 The Wren 6. 36 18 Staff must have regular, recorded supervision meetings, at least 6 times per year. (Previous requirement of the 1 June 2005 not met). 30.9.05 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 42 Good Practice Recommendations On receipt of the Portable Appliance Test Certificate a copy should be forwarded to the Commission for Social Care Inspection. 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