Inspection on 24/04/07 for The Wren

This inspection was carried out on 24th April 2007.

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 no outstanding requirements from the previous inspection report, but made 7 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 20/10/06

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 John Oliver Unannounced Inspection 24th April 2007 10:00 The Wren DS0000021630.V334597.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.V334597.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.V334597.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.V334597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 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.V334597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the last inspection visit to The Wren in October 2006. A visit to the home took place on 24 & 25 April 2007 over a total period of 10 hours and the home was not told about the visit beforehand. During this visit the inspector had a look around the home and looked at paperwork that must be kept by the home to show that it is being run properly. Another way that was used to find out more about the home was by talking with some of the people and staff who were in the home on the days of the visits. Some of the people living in the home have very little verbal communication and so although they were not able to express their views directly, time was spent watching how staff talked to and supported people. The home has the support of the two managers’ who are both registered with the CSCI, Mrs Margaret Monteith and Ms Dorna Monteith. A lot of time was spent with both managers talking about the running and management of the home. At the last inspection visit of The Wren there was a few concerns about how medication was being dealt with in the home and, because of this, a Pharmacist inspector came on day one of this inspection visit and carried out a full check of medication. What the service does well: The home provides help and support to people whose needs range from prompting and encouragement to high levels of both personal and physical support. The relationships between people and staff were seen as very positive and respectful and both the staff and managers had an understanding of the specific needs of the individual people living in the home. Staffing levels were consistent and there were appropriate numbers of staff to meet the needs of the people living in the home. A good standard of personal care and hygiene is maintained and people are well clothed and groomed. Managers understand the individual needs of each person when taking their medication. The managers make sure each person is given their medication in an appropriate way to ensure their health is not at risk. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Each person living in the home has a file and included in that file is a care plan that gives information to care staff about how best to help the person in managing their day-to-day lives. Information in the files was not kept in the same way in each file and was confusing to anyone reading the information for the first time. Although the care plans had lots of information in them some of the information was not enough. Much of the information told staff what they must do for the person rather than what they must do with the person. This can reduce or take away some of the independence, freedom and choice that an individual person may have. The help and support people need ranges from prompting and encouragement to high levels of personal, emotional and behavioural support. It is really important that the care plans show how such support must be offered/given to the person in the most appropriate way and have systems in place to respond to a persons’ needs in the best way for the individual e.g. proactive or reactive. Some information was available in the home such as the Complaint Procedure but the information was not enough to clearly tell people what they should do if they have a complaint. It would also be better if information like this could also be offered in different styles such as: pictures, large print and in plain English. The paperwork and administration systems for the home such as records, staff rotas, care plans; risk assessments and health care records are mainly kept and maintained by the two registered managers. Speaking with both managers during the visit demonstrated that they both had very different management styles. One manager saw record keeping and maintaining the required paperwork as important and the other manager, not so important. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 7 Both registered managers must appropriately maintain all the required records and paperwork, in a consistent and suitable way in order that the people living and working in the home receive the same information, support and direction from both managers and are not confused by the different management styles. The managers must make sure that they keep clear and accurate medication records and that they can account for all medicines. The managers must also make sure that people are given their medication in the way the doctor prescribes it, to ensure that the health of the individual person is not at risk from harm. 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 summary of this inspection report can be made available in other formats on request. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 8 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.V334597.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were fully assessed before being offered a placement in The Wren. EVIDENCE: There had been no new admissions into The Wren since the last inspection visit in October 2006. The files of two people living in the home were randomly selected and were found to contain copies of the Community Care Assessments. A recent survey carried out by the local authority included questionnaires being sent to the relatives of people living in the home. Of the five returned, three confirmed that discussions had taken place prior to their relative moving into The Wren and that their views and opinions had been taken into account. It would be seen as good practice if the managers confirmed in writing, following such assessments, that the individuals’ needs could/could not be met by the home. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 10 The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although each person had a plan of care, these required further information including in them to focus on the needs and goals of people. EVIDENCE: Each person had an individual care file that included the care plan and other information relevant to maintaining the lifestyle for that individual person. The contents of these files were ad-hoc and were not consistent in the way the file was put together. The format of the care plan has been developed from a standardised template provided by a professional consultancy. Discussion with the managers indicated that it would be better if the standardised format was reviewed and changed where necessary to enable relevant and appropriate information be included where required. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 12 Other than some parts of the plan being written in the first person, there was very little evidence of Person Centred Planning taking place, although some staff had received training in this. The inconsistency in the way files were put together made following the care plans and linking the risk assessments and other information difficult. Care plans had been maintained and updated by one of the managers but there was little evidence that the individual person had been involved in developing or reviewing their plan of care. Care plan files are kept in the main office in the basement of the home and are not easily accessible to staff. It is important to the health and wellbeing of each person living in the home that the staff have appropriate access to information about the individual person on a day-to-day basis in order to help maintain their lifestyle that is the most appropriate way to them. Although some risk assessments were in place, the management of the identified risk was not always clear and did not provide details of any proactive/reactive strategies that could be used. One example being: “…has used physical and non physical aggression towards service users….has used….fists towards staff and kicked other service users without provocation”. The information for staff to deal with this was: “The staff on duty should intervene and assist…and/or service user involved to vacate the area…”. Information needs to be more specific and this was fully discussed with the management team. People were seen to be actively moving around the house with staff observing discreetly. One member of staff was seen to use ‘distraction techniques’ when a person wanted to attempt something that could have placed them at risk. This is the type of information that needs to be included in the care plans/risk assessments for individual people. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s involvement and participation in activities both in-house and in the local community are limited which could prevent choice and independence being maintained. EVIDENCE: The home had continued to offer limited support and choices for people to participate in a range of social, leisure and community based activities that people valued and enjoyed. Of the seven people living in the home, five regularly attended day care facilities provided by the local authority. This means that the number of people in the home ranged from 2 to 7 on any particular day of the week and routines of the home appeared to be based on this factor. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 14 There has been some improvement in supporting people to access the local community and to participate in things that they enjoy doing. One member of the staff team (supervisor) had developed an ‘activities file’ and there was evidence that people living in the home were being supported to attend events in the local community such as football matches, going shopping and, attending the local social club. Following such visits, a brief report is written to indicate how the activity went, whether it was enjoyed and the outcome for the person. Although the way people living in the home were dressed presented a positive image and some indication of their individuality there was little evidence to suggest that any person was actively involved in shopping for their own clothes. This should be considered, especially as the management of the home have recently purchased a motor vehicle for the sole use of the people living in the home and have employed a driver. People living in the home are not encouraged to participate in household chores. This should be considered in order to further promote independence. Mealtimes at the home were planned and not rushed. A menu is planned over a four weekly cycle and there was evidence that a wide variety of food was available and people were offered a variety of nutritious and balanced meals. The supervisor was able to demonstrate how choice was offered to one particular person with limited verbal communication. One care plan seen indicated that the individual ‘…may want food cutting up’. Whether staff had to be proactive or reactive in this matter was not stated which could mean that the individuals’ independence could be compromised. One letter sent to the home by a relative stated: “I am particularly impressed with the way you have regulated…diet… now has good food, properly prepared and cooked meals with all the consequent benefits for…weight and health”. “…knowing I will find…happy and content, clean, and obviously enjoying …life at the Wren”. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed in the way in which records are kept and in the way medication is administered to prevent the risk of harm to people living in the home. EVIDENCE: People are supported with their personal care in the privacy of their own bedroom. Observation of staff demonstrated that the individuals’ privacy and dignity was considered at all times. Although care plans contained information relating to the individual support needs of the person the detail and level of recording varied and some care plans required more specific details to ensure that the person’s needs would be met in the most appropriate way and in accordance with their wishes. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 16 A number of people living in the home had specific health needs relating to epilepsy. This information was comprehensive and in the persons individual file. A separate ‘Epilepsy Episodes’ file was accessible to all staff. This file also contained comprehensive details relating to each person and how, if they have an epilepsy seizure, this should be managed. A letter from the relative of one person who suffers with epileptic seizures stated: “…wellbeing is thoughtfully managed…not least…periodic and unpredictable epileptic seizures”. One person spoken to said: “…very happy living here”, “I like my bedroom”. From this persons interaction with staff it was clear that he had a good and trusted relationship. The Pharmacist Inspector carried out an assessment of the medication practice in the home and found a number of concerns regarding the recording, administration and safe handling of medication. The record keeping was inadequate and the Medication Administration Record sheets (MAR’s) had a number of missing signatures so it was difficult to tell if medicines had been administered properly. No records were kept of medication received into the home and no system was available to account for all medicines prescribed by a doctor to his or her patient. There was no system in place to make sure that a stock of medication was always available for the individual person. On some days there was evidence that medication was not available and could not be administered as directed, which could put the health of the individual at significant risk. Pain relief medication could not be given at night without staff ringing a member of the management team at home to give consent. Staff supporting people during the nighttime must have access to medication to meet the needs of the individual and must also have the appropriate training to make sure that they are competent to give out medication safely. Some people living in the home require medication to be given covertly and although staff in the home demonstrated a clear understanding of the individual’s need when doing this no prior consent had been obtained from the relevant doctor for this process to be carried out. It is important that this consent is obtained for people who require their medication being administered in this way. Following a telephone conversation with the manager on 1 May 2007 it was confirmed that arrangements had been made to meet with the supplying pharmacy, that the local GP will provide written confirmation of medication that can be administered to their patient(s) covertly and, the GP will carry out a full review of each patients’ medication by the end of June 07. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems, policies and procedures in place to protect people need to be more robust to fully protect them. EVIDENCE: Information relating to dealing with complaints was insufficient. No specific complaints policy or procedure was in place. A notice in the hallway provided limited information and was directed at ‘Service User’s families and friends…’ rather than being directed to the people living in the home or being in a suitable format for the individual to be able to easily understand. The manager confirmed that no complaints had been made to the home since the last key inspection visit in October 2006. No complaints register is kept and this was fully discussed along with the importance of maintaining appropriate documentation. Watching how people interacted with staff demonstrated that should they wish to make their feelings known, they could by their individual method of communication. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 18 Although the home had a policy and procedure relating to the Protection of Vulnerable Adults (POVA) this information was confusing. A copy of the local authority’s guidance ‘No Secrets’ was available. The manager was clear about the processes to follow should an allegation of abuse be made. Staff had not received any training in POVA but places had been secured on a training course. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides people with a homely and comfortable environment but some areas of risk were not recorded which could place people at risk of harm. EVIDENCE: The home provides a comfortable, reasonably well-maintained and homely environment that has the layout, space, aids and adaptations needed to meet people’s needs. Parts of the home were beginning to look a little ‘drab’ and would benefit from redecoration and repainting especially on the corridors and communal areas. Some parts of the building are surrounded by trees making some areas of the home appear darker than it actually is. This could be a potential risk to people The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 20 living in the home and should be taken into consideration when planning a programme of redecoration. Bedrooms varied in personalisation and furnishings were showing signs of wear and tear including a number of wardrobe doors and drawer fronts that were missing handles making them difficult to open. Very little of the furnishings matched and beds varied in size from single to double in order to meet the needs of the individual. Three bedrooms seen contained showers that were not used by the people whose rooms they are. Consideration should be given to making sure that these showers cannot be turned on, as this would pose a potential risk to the individual person. Radiators throughout the home had thermostatic controls but were unguarded with no risk assessments in place. It is important that a full audit of all radiators throughout the home is undertaken and risk assessments put in place to minimise any risk to people living in the home from entrapment. Where the risk cannot be effectively minimised, then guards must be fitted. Following a conversation with the supervisor on 1 May 2007 it was confirmed that an audit of all radiators had been started. Carpets throughout the home were beginning to show signs of wear and tear but are regularly deep cleaned by a professional cleaning company. In one particular bedroom identified to the supervisor there was a hole in one part of the carpet. As this person needs help with transferring from wheelchair to bed there is a risk of slips, trips or falls and the carpet must be replaced. As an intermediate measure, the supervisor said that he would cover the hole with some ‘duck’ tape to reduce the immediate risk. Following a conversation with the supervisor on 1 May 2007 it was confirmed that this intermediate measure had been carried out. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Lack of staff training and formal supervision has the potential to place people living in the home at risk. EVIDENCE: Staff spoken to were able to demonstrate an understanding of the needs of people living in the home and appropriate interaction between some staff and individual people was seen to take place. Rotas demonstrated that enough staff were deployed to meet the needs of those people living in the home at the time of this visit. Each member of staff had an individual training and development file. These were inconsistent in their contents and were difficult to follow. Of the two files examined copies of various training certificates were included however, the only recent training evidenced by a certificate was a one day training session on Epilepsy carried out by the Manchester Learning Disability Partnership The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 22 (MLDP). It is important that all staff receive regular training that helps them to carry out their job safely and efficiently. The manager confirmed that of the 9 care staff employed, three had achieved the National Vocational Qualification (NVQ) Level II. One member of staff said: “We do get some training”. It was confirmed by the manager that since the last inspection visit in October 2006 only one new employee had joined the staff team. The file of this individual was made available and was found to include all relevant and appropriate documentation. Formal supervision of staff was not routinely carried out which does not give staff relevant opportunities to discuss their training needs and other issues that may be of concern to them. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistent management practice has the potential to place people at risk. EVIDENCE: The management team of the home consists of two registered managers – Mrs Margaret Monteith and Miss Dorna Monteith. A supervisor has responsibility for health and safety throughout the home and also does much of the cooking, food purchasing and maintenance. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 24 Both registered managers have very different styles of management and this is causing inconsistency in administrative and other management processes. There are two offices that are used for administration purposes in the basement of the home. These are not small rooms but do feel oppressive because of the amount of ad-hoc paperwork, files and other things being stored in them. This has resulted in both old and new formats of the same documentation being used at the same time – causing confusion. It is important that both managers carry out their roles in a consistent manner in order to maintain effective and clear management of the home. One member of staff spoken to said: “We are supported by management” and, “Management answer my questions”. There was no particular system in place to undertake quality monitoring of the service other than a questionnaire that had been developed to give to family/advocates and friends of people living in the home. There was no evidence to show that any of these questionnaires had been returned to the home. There was however letters on file that had been received from relatives of people living in the home. Comments seen in these letters included: “It has given me great peace of mind to know that…is looked after with such kindness and professionalism, and that all aspects of …wellbeing are thoroughly and thoughtfully managed..” There is a policy and procedure file in place but this had not been reviewed or updated for quite some time although the management had purchased a professional management support system. It is important that staff have appropriate and up to date information in place to support them in the job that they do. Evidence was available to demonstrate that regular servicing and maintenance of equipment was taking place. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 25 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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 2 X The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Information contained within a care plan must be completed with specific detail as to how individual assistance is to be offered and, wherever possible, the person whose care plan it is should be fully involved in this process. (a) When medication is administered to people who use the service it must be clearly and accurately recorded and records must clearly demonstrate that all medication can be accounted for. (b) Medication must be administered to people who use the service in accordance with the prescribers’ directions to ensure that the individuals’ health is not put at risk. Sufficient prescribed medication must be available at all times to Version 5.2 Page 27 Timescale for action 29/06/07 2. YA20 13 (2) 24/04/07 (c) The Wren DS0000021630.V334597.R01.S.doc 3. YA20 13 (2) 4. YA20 13 (2) 5. YA24 13 (4)(a) people who use the service to ensure continuity of treatment. Any medication that needs to 01/06/07 be given covertly must only be done so with the consent of the persons’ GP and other interested parties with all relevant documentation being completed. Staff with the responsibility 01/07/07 for administering medication to people living in the home must receive appropriate training and be assessed as competent to do so. (a) Showers within the 08/06/07 bedrooms of the home must be assessed for the risk they present to the people who use the service and action taken to minimise this identified risk. (b) Radiators within the home must be assessed for the risk they present to the people who use the service and action taken to minimise this identified risk. 16/06/07 6. YA24 13(4)(a) 7. YA24 13 (4) & 23 (2) (b) The carpet in the bedroom identified to the supervisor must be replaced to minimise the identified risk to the person whose room it is. The registered person must make sure that the premises are safe and well maintained. This includes minimising risks to people living in the home by repairing or replacing damaged furniture that could be a risk to the individual person. 29/06/07 The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 28 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 YA2 Good Practice Recommendations It is recommended that following the pre-admission assessments it would be good practice if the manager writes to all interested parties to inform them that The Wren can/cannot meet the individual persons needs. It is strongly recommended that the standardised document used to develop a care plan be reviewed and updated into a more suitable format for the service being provided. It is strongly recommended that risk assessments include specific details of how the identified risk is to be managed and that the risk assessment(s) ‘link’ to individual care plans for consistency of such information. It is strongly recommended that the care plan files for each person living in The Wren is made available to staff at all times to ensure that information is readily available to them about the care needs of each person living in the home. It is strongly recommended that opportunities are made available to each person living in the home to participate in accessing the local community e.g. to purchase their own clothes. It is also recommended that consideration be given to encouraging those people who are able, to participate in household chores to further promote independence. It is strongly recommended that information that is made available regarding complaints be reviewed and updated to include all relevant guidance and be made available in suitable formats. A record of complaints should be kept that includes the nature of the investigation, the outcome of the investigation and whether or not the complainant is satisfied. It is recommended that an effective system is put into place to identify and address minor remedial items in connection with the building. All staff training should be reviewed and arrangements made for staff to receive training that is appropriate to the jobs they do. All staff working in the home should receive regular, DS0000021630.V334597.R01.S.doc Version 5.2 Page 29 2. YA6 3. YA6 4. YA6 5. YA16 6. YA22 7. 8. 9. The Wren YA24 YA35 YA36 10. YA41 recorded supervision meetings with their line manager. It is strongly recommended that all policies and procedures be reviewed and updated where necessary and that appropriate information is made available to staff at all times. The Wren DS0000021630.V334597.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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