Inspection on 21/02/06 for Wakes Hall

This inspection was carried out on 21st February 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wakes Hall 30/08/07

Wakes Hall 26/09/06

Wakes Hall 09/11/05

Wakes Hall 21/12/04

Wakes Hall 14/06/04

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Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Wakes Hall Wakes Colne Colchester Essex CO6 2DB Lead Inspector Andrea Carter Unannounced Inspection 21st February 2006 09:50 Wakes Hall DS0000017991.V284264.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 Wakes Hall DS0000017991.V284264.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. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wakes Hall Address Wakes Colne Colchester Essex CO6 2DB 01787 222044 01787 222649 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) SCOPE Mrs Carrie Nicola Irvine Care Home 28 Category(ies) of Learning disability (28), Learning disability over registration, with number 65 years of age (9), Physical disability (28), of places Physical disability over 65 years of age (9) Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a physical disability, who may also have a learning disability (not to exceed 28 persons) Nine persons of either sex, aged 65 years and over, who require care by reason of a physical disability, and who may also have a learning disability, whose names were made known to the Commission in March 2003 The total number of service users accommodated in the home must not exceed 28 persons 9th November 2005 2. 3. Date of last inspection Brief Description of the Service: Wakes Hall is a large Georgian building situated in a rural community near the village of Wakes Colne, in the county of Essex. The nearest main town of Colchester is approximately eight miles away. Local facilities include a public house, a post office and public transport links. Although gaining access to these facilities is difficult for people using wheelchairs, the service users have use of appropriate taxi services and the home’s own specially adapted vehicles. Wakes Hall has large grounds and gardens. There are seven self-contained bungalows with one having double bedroom facilities. These bungalows accommodate service users who may be preparing to move from Wakes Hall to more independent accommodation. The main building has been converted to meet the needs of people with physical disabilities, which includes twenty single bedrooms on two levels. The second level is reached by a passenger lift. There are three bathrooms, four showers and ten toilets. Service users are divided into two smaller groups to create a group living concept. Each group has separate facilities which include a living room, a kitchen and a dining area. The home has a day care centre attached with a separate entrance. The service users at Wakes Hall use this facility for activities and meetings. Wakes Hall DS0000017991.V284264.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 over one day and fieldwork included discussion with the deputy manager, who is managing the site in the registered mangers absence due to sick leave. The administration officer provide sound evidence around service users finance.. A full guided tour of the premises and introduction to service users. One service user interview was undertaken. Five key standards were focused on all of which satisfactorily met National Minimum standards. The previous inspections requirements will be covered in the main body of the report and at present remain unmet. What the service does well: What has improved since the last inspection? What they could do better: Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 6 The service will help service users to access holidays abroad, but currently staff are prohibited to accompany due to an organisational procedure and associated policy. The area for refurbishment has been identified as part of scheduled remedial work to be undertaken within the organisation’s property improvement programme. This work is identified and will be completed in due course. Currently the registered manager is off sick therefore has been unable to complete the NVQ Registered Mangers Award. 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. Wakes Hall DS0000017991.V284264.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 Wakes Hall DS0000017991.V284264.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): These standards were not focused on within this inspection. EVIDENCE: Wakes Hall DS0000017991.V284264.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 Service users make decisions about their lives with assistance as needed. EVIDENCE: The service had developed informative care plans that evidenced positive examples of individuals making choices in relation to their every day lives. Key workers have supported individuals to make choice around the redecoration and furnishing of their individual rooms Regular service user meetings facilitate choice within the wider context of the home. Menu planning, information around proposed staff changes and recruitment all give rise to the opportunity to express opinions and formulate judgments and decisions about their home and the day to day running. Attendance at reviews is the choice of the individual and support is given to compile and collate the individual’s views and current and future aspirations. Finance records tracked evidenced a sound system and associated processes. Service users have locked cabinets in which to keep their money. One individual has a parental appointee. Systems are in place to ensure service users money is handled appropriately and receipts retained for all expenditure. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 10 Two service users monies and documentation were inspected and the balance available accurately reflected expenditure. Two signatures and senior management authorisation is required for the withdrawal of monies requested by individuals or supporting key workers. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 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): 13 14 and 15 Service users are part of the local community Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. EVIDENCE: The service has appointed a senior staff member to orchestrate all the internal and external activities programme. On the day of the inspection service users were observed participating within a cultural studies session, with the course being facilitated by an external tutor. The service provides a wide range of educational and recreational courses and activities. This includes trampolining, rebounds therapy, modern art, adult educational courses accessed at the Wilson Marriage Centre in Colchester. Internally courses are currently run around the subjects of numeracy, literacy, music and unlimited, computer, music and movement, and sensory sessions. External tutors facilitate all of theses identified courses. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 12 There is also the opportunity to participate within cookery sessions as orchestrated by the volunteer cook There is a wide programme of entertainment available and recent visits have included the cinema, a live cabaret, and tropical wings butterfly centre. All identified within the forum of the service users meetings. Two service users contact arrangements were inspected. One individual has regular family contact, they go home for overnight stays, and their parents visit the home and go out locally for meals with their son/daughter. Other family members contact by phone and a recent family party was attended and transport and support given by the individual’s key worker to enable them to attend. The opportunity for any individual to access the unit’s transport is available to support home visits or community access. Previously couples within the establishment have been married and currently there is one shared bungalow on the site. The previous inspection identified that the current national policy does enable individuals to travel abroad. The service facilitates all appropriate arrangements but staff are unable to accompany due to insurance cover. CSCI is currently with the services Head office to clarify this point. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 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 Service users receive personal support in the way they prefer and require. EVIDENCE: Two care plans were sampled. The documents gave a positive example of individual support around the areas of bathing, moving and handling, getting up and retiring. These areas clearly identified the level of personal choice this individual had in their every day life. Appropriate equipment was available across the service to support the physical needs of individuals. Outside specialists support individuals with a range of needs, including physiotherapy, occupational therapy and psychology. The service receives regular input form the speech and language therapy department and a wide range of communication aids and systems are in place. The service is investigating opportunities for staff to develop their current communication skills. This will include inclusive communication and incorporating the use of sign, pictures, photos, real objects and simple clear words. Attendance on this course will certainly enhance the communication systems already in place within the unit. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 14 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): These standards were not focused on during this inspection. EVIDENCE: Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 15 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 27 The service generally presents as a comfortable and safe environment for service users. The downstairs bathroom and shower room does not meet individual needs. EVIDENCE: The previous inspection identified the need for the refurbishment of the corridor leading to the multi sensory room. This requirement to refurbishment was also identified for the downstairs toilet and shower room. Currently neither of these areas have been addressed. The work has been costed into the budget for 2006/07 for completion. Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 16 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 An effective staff team supports service users EVIDENCE: The home’s current management structure is a manager, team leader and two seniors with a third due to commence employment shortly. Each senior takes line management responsibility of a shift on a daily basis. The service runs three shifts over a 24-hour period. Additional to the care team is a full time housekeeper, domestic, laundry person, maintenance person/driver and two cooks. The home has vacancies on the care team but rotas indicated the use of agency staff known to service users to ensure consistency and continuity within in the service. Staff meetings are held regularly and communication systems are all fully outlined within the individuals care plan. The service is planning to run a two hour training session on a weekly basis to enable staff to enhance their skills within specific areas. Wakes Hall DS0000017991.V284264.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): 37 Service user benefit form a well run home. EVIDENCE: The previous inspection identified the need for the current registered manager to complete the qualification of the registered managers award level IV Due to long-term sickness this has not been achieved. Wakes Hall DS0000017991.V284264.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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 X 23 x ENVIRONMENT Standard No Score 24 2 25 X 26 x 27 2 28 X 29 X 30 x STAFFING Standard No Score 31 X 32 x 33 3 34 X 35 X 36 x 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 3 14 2 15 3 16 X 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X x 2 X X X X X X Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 19 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 YA14 Regulation 16(n) Requirement The registered person must consider how to enhance service users’ ability and desire to take holidays abroad. The registered provider must carried out works to the premises as indicated in the Environment section of the report. The registered provider must carried out works to the premises as indicated in the Environment section of the report. The registered person must ensure that the manager is qualified to NVQ Level 4 in Management and Care. This is a repeat requirement. Timescale for action 28/06/06 2. YA27 13 28/06/06 3. YA24 13 28/06/06 4. YA37 9 (2)(i) 28/06/06 Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wakes Hall DS0000017991.V284264.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Wakes Hall DS0000017991.V284264.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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