Inspection on 03/03/06 for The Wren

This inspection was carried out on 3rd March 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 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 24/04/07

The Wren 20/10/06

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 Unannounced Inspection 3rd March 2006 10.00 The Wren DS0000021630.V278979.R01.S.doc Version 5.1 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.V278979.R01.S.doc Version 5.1 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.V278979.R01.S.doc Version 5.1 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 Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 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 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 DS0000021630.V278979.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a 3 1/2 period on the 3 March 2006. During the inspection, time was spent talking with staff members and the registered manager. Time was also spent with some of the residents. In addition, a sample of people’s files, records and other relevant documentation were examined. 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: What has improved since the last inspection? What they could do better: The home did not have a planned renewal and maintenance programme in place. The home was showing signs of wear and tear of the décor and furnishings. The manager had arranged for the replacement of some of the furnishings but this needed to be on a planned basis. A copy of the maintenance programme should be forwarded to the Commission for Social Care Inspection. Samples of staff files were inspected. Staff files did not contain all the relevant information as required in Schedule 2 of the Care Home Regulations 2002. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 6 The manager reported that staff received regular supervision however; this was not in accordance with the requirement of a minimum of six times per year. The home also needed to develop a formal training plan for staff. The home managers needed to coordinate their roles and responsibilities to ensure that when one manager was absent from the home the other manager was aware of what management issues had been undertake and had a clear understanding of where information was kept. 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.V278979.R01.S.doc Version 5.1 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.V278979.R01.S.doc Version 5.1 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): 1&2 On arrival residents are provided with information about the home and its services and their needs are assessed and identified. EVIDENCE: The home had a Statement of Purpose and a Service Users’ Guide however, the manager said this was still under review and the home was in discussion with other professionals to formulate a pictorial user-friendly document. This is an outstanding requirement from the previous two inspections and has been reiterated at this inspection. The manger said that all new potential new residents were able to visit the home and information was provided verbally as well as the written documents being given to the potential residents representative. All residents at the home were referred via a care manager and all had a comprehensive assessment of need. The home also undertook an assessment of the individual needs of the prospective service user to ensure that the home could meet the potential residents needs. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 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): 7 The home supported residents as far as possible, due to the residents complex needs, to make informed choices about their lives. EVIDENCE: The residents at the home had complex needs, which reduced their ability to make choices independently. The manager and staff supported the residents to make as far as possible informed choices by consulting with relatives and advocates. Choices were reviewed on a continual basis when the staff had worked with a resident and was aware of the individuals likes and dislikes. Additional information gained was added to the residents care plan. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 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 the following standard(s): 15, 16 & 17 Residents’ rights and choices are respected and they have the opportunities and support to maintain family and friend relationships. EVIDENCE: The residents were supported to maintain appropriate personal and family relationships. Family and friends were able to visit the resident within their home. The home had a private lounge area where family and friends could meet in private. Staff and management were observed to treat the resident with dignity and respect. They were supported to maintain social activities within the community and access local facilities in accordance with their wishes. Residents’ views on their diet were gained and where a resident was unable to verbally express their view information was gained via family, advocates and observations. The home provided a varied and nutritious menu and maintained a wide selection of food in store to cater for the residents needs. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 11 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): None of these standards were assessed at this inspection. EVIDENCE: The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 12 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 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 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 DS0000021630.V278979.R01.S.doc Version 5.1 Page 13 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, 26, 27 & 30 The standard of decoration in most areas of the home provided a comfortable and welcoming environment. There were however some areas that required redecoration/ refurbishment. 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 Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 14 Some of the resident’s bedrooms required the bedroom furniture to be replaced and wardrobes to be secured to the walls to reduce the risk of being pulled over. Toilet and bathroom facilities were accessible and appropriate aids and adaptations were in place. The home was clean and free from odours although as previously mentioned there were some areas of the home that showed signs of ‘wear and tear’ and required redecoration. At the time of the inspection all the carpets within the home were being steam cleaned. The manager said that this was a regular contract and was undertaken every three months. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 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 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): 33, 34, 35 & 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: Selections of staff files were viewed. Staff files did not contain all the relevant paperwork as required by the Care Home Regulations 2002. This had been identified at the previous inspection and the manager said that the files were being reviewed. Where only one reference had been obtained a further reference was being requested. Criminal Record Bureau enhanced disclosures were in place for current members of staff although some of the disclosures had been carried forward from previous employment. This was discussed with the manager by the inspector. Staff files did not contain all information regarding the training undertaken by staff. The manager said that this was available on another file but was unclear where the file was. It was strongly recommended that all information regarding staffing be maintained on one individual file for each member of staff to avoid any risk of information being mislaid. Each member of staff must have an assessment of their training needs and a training and development plan, linked The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 16 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. The manager said that staff supervision was undertaken on a regular basis; again this information was not available on all the sample of staff files viewed. Staff must receive formal supervision at a minimum of six times per year and a record of the supervision maintained on their individual files. Staff spoken to say that they received supervision but were unclear as to how often that supervision took place. The managers worked alongside the members of staff and provided informal supervision on a daily basis. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 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 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): 39 The home gained the views of the service users and their relatives and friends. EVIDENCE: The home had developed a quality assurance document to gain the views of the relatives/friends and other professionals’ views regarding the care and support provided to the residents. Due to the complex needs of the residents they were unable to formally express their views about the service. The manager said that the residents were continually monitored and observed to ensure that their needs were being met appropriately. The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 18 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 2 2 X 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 X 30 x STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 2 X X X X The Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 19 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 YA1 Regulation 4 Requirement The Service Users 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) Timescale for action 30/07/06 2. YA24 16 30/06/07 3. YA33 18 30/06/06 4. YA34 18 5. YA35 18 The home must operate a robust 30/06/06 recruitment process and obtain two written references for all new staff in order to protect residents. A training and development plan, 30/06/06 linked to the homes aims and objectives and service users needs must be implemented (Previous timescale of the 1 June 2005 not met). DS0000021630.V278979.R01.S.doc Version 5.1 Page 20 The Wren 6. YA36 18 7 YA39 18 Staff must have regular, recorded supervision meetings, at least 6 times per year. (Previous requirement of the 1 June 2005 not met). A quality assurance format must be developed to gain the wishes and views of the residents within the home. 30/06/06 30/07/06 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 Wren DS0000021630.V278979.R01.S.doc Version 5.1 Page 21 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.V278979.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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