Inspection on 30/08/07 for Wakes Hall

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wakes Hall 26/09/06

Wakes Hall 21/02/06

Wakes Hall 09/11/05

Wakes Hall 21/12/04

Wakes Hall 14/06/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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 Ray Finney Unannounced Inspection 30th August 2007 10:00 Wakes Hall DS0000017991.V349875.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 Wakes Hall DS0000017991.V349875.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. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wakes Hall Address Wakes Colne Colchester Essex CO6 2DB 01787 222044 01787 222649 wakes.hall@scope.org.uk www.scope.org.uk SCOPE 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 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.V349875.R01.S.doc Version 5.2 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 26th September 2006 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. 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, people living at Wakes Hall 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, one with double bedroom facilities. These bungalows accommodate people 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 and has twenty single bedrooms on two levels. The second level is reached by a passenger lift. There are three bathrooms, four showers and ten toilets. The home is divided into two smaller units within the main building. 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. living at Wakes Hall use this facility for activities and meetings. People The home charges between £466.76 and £1,323.67 a week for the service they provide. This information was given to us in August 2007. Information about the home can be obtained by contacting the manager; inspection reports are available from the home and from the CSCI website www.csci.org.uk Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as staff rotas, care plans and staff files. The manager completed an Annual Quality Assurance Assessment with information about the home. Throughout the report this document will be referred to as the ‘AQAA’. A visit to the home took place on 30th August 2007; this included a tour of the premises, discussions with the manager, members of staff, a visiting community nurse and conversations with people living in the home. Completed surveys were received from the relatives of people living in the home and a local health care professional. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and the inspector was given every assistance from the manager and staff. What the service does well: People living at Wakes Hall benefit from opportunities for personal development and a fulfilling lifestyle. There is an excellent programme of activities and college courses; access to community facilities is good. The home values each person as an individual, empowering them to make decisions and listening to their views. Wakes Hall is good at maintaining family links between people living in the home and their relatives. Relatives are complimentary about the service; one said, “Wakes Hall seems to be the perfect place for my relative” and another said that the home is ”faultless”. The standard of care provided by the home is highly regarded by both relatives and health professionals. One relative said, “the physical care is excellent” and a healthcare professional said, “I have always been impressed by the support given”. The home is well managed and people living there benefit from being supported by well-trained and well-supervised staff. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 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 summary of this inspection report can be made available in other formats on request. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Wakes Hall can be confident they will receive enough information about the home and their needs will be assessed before admission. EVIDENCE: Since the last inspection the home’s Statement of Purpose has been reviewed. The manager said that this is to reflect SCOPE’S commitment to promoting equality and diversity. The home recognises people have a range of communication needs and produce the Service User Guide in a variety of formats, including large print, an audio version and one using symbols. Information in the AQAA states that a new service brochure will be produced soon. A relative who completed a survey said, “Staff always find details of anything we want to know about, if it has not already been forthcoming”. Through discussions with the manager, she is able to demonstrate a good awareness of the importance of a good assessment process so that they can make sure the home can meet the person’s needs. A sample of three people’s records examined all contain comprehensive assessments. The AQAA states that a ‘taster’ stay is encouraged after the initial assessment is carried out. The home offers a three-month trial placement, which is reviewed after six weeks. To offer support to people who have just moved to the home, they plan to pilot a ‘service user mentoring scheme’ to offer new residents a fellow Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 9 resident for mentoring support during their trial period. Before the scheme can start the proposal is to be discussed at service user’s committee meetings. Records examined show that there are contracts in place between the home and the individual. Contracts examined are signed by a representative on behalf of the person living in the home. Contracts are written in clear language and clearly state things that the service provider will do and what is expected of the person moving in to the home. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. People living in Wakes Hall benefit from a well developed care-planning system that recognises and values people’s individuality. They are supported to make decisions about their lives and to take risks within their capacity to understand. EVIDENCE: The AQAA states that the home operates “a person centred care planning system which identifies the needs, wishes and aspirations of people” and that people living in the home are involved in devising and review of individual plans. This was confirmed by records examined on the day of the inspection. A sample of three care plans were looked at, including the records of the person most recently admitted to the home. The care plans start with a ‘Life Story’ giving the family and cultural background, early life, adult life and major life events. This is written from the point of view of the individual. The care plans are written in clear language and cover a wide range of needs including mobility, getting up, continence, Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 11 bathing, personal grooming, choice/decision making, self image, dietary needs, communication, leisure/hobbies, daily living skills, emotional support, relationships/sexual expression, going to bed, night time assistance, finance, religious and cultural needs. One care plan contains a protocol giving staff very clear guidelines on strategies to use to meet a person’s needs around behaviours that challenge. Trigger factors are identified and there are guidelines for staff on working in a consistent and appropriate manner. Care plans examined all contain evidence of recent Social Services review. The AQAA states that care plans are reviewed at least every three months and are also reviewed at key worker supervisions. Records examined also contain daily recording sheets relating to the individual care plans. The home has a new programme of training for staff on care planning. Discussions with the manager and staff show that the home uses a variety of means of supporting people to make decisions. There are regular residents’ meetings and residents’ activity meetings. Information provided by the home’s Quality Assurance system shows a high level of satisfaction with the service from people living there, with all surveys returned showing people are satisfied with the level of choice and control they have over their lives. A survey returned to us at the Commission by the relative of someone in the home said, “My relative likes to lie in bed some mornings. They always have the choice and is not pressurised to do something they don’t want to do”. The AQAA states that there is a comprehensive risk assessment and management system in operation. This was confirmed by records examined on the day of the inspection. Care plans checked all contain risk assessments, including one on moving and handling, finances and a comprehensive general risk assessment. The general risk assessment identifies the area of risk and who is at risk, what harm may occur and what precautions are in place to reduce the risk. Any other relevant risk assessment in place depends on individual needs. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 12 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, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home have excellent opportunities to participate in activities that are appropriate to their needs and they are supported to access facilities in the local community. The home ensures that people living there build and maintain relationships with their families. The people living in Wakes Hall benefit from a well balanced, nutritional and varied diet. EVIDENCE: On the day of the inspection the activity co-ordinator was arranging applications for courses for the new college term about to start. Records examined confirm that the home continues to support people with their education and training. The home is building on the pilot scheme for people to have training around empowerment that was reported at the last inspection, by holding training workshops for people living in the home. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 13 Standards around occupation and education were exceeded at the last inspection and the home continues to provide a wide range of opportunities for people to take part in activities of their choice. The activities co-ordinator is working with people to develop new activity files, which contain pictures and other evidence of the things that people are doing. The activity files are used both as an activity record and as a way for people to communicate what they have been doing to friends and relatives and to help them communicate their likes and wishes around leisure activities. The AQAA states that this is a pilot scheme that has been introduced so that people can keep pictorial diaries as a ‘meaningful and appropriate’ record of lifestyle choices. A quarterly newsletter has been produced that provides evidence with pictures of activities that take place. There are minutes of resident’s committee meetings and resident’s activity group meetings that show people’s involvement in making decisions around what activities take place. The home’s Quality Assurance surveys show that 84 of people living there are satisfied with the social, recreational and educational opportunities offered by the home. On the day of the inspection we observed activities taking place in the training room. People were obviously enjoying themselves supported by staff and a volunteer. Relatives who completed surveys for us at the Commission said that the home provides “good care, good communication and good activities” and “my relative is well and happy and seems to be kept stimulated”. A completed survey from a healthcare professional said, “I have always felt that the service tries hard to give maximum support to the clients to live as full a life as possible.” Activity records examined also contain ample evidence of taking part in activities in the community. A series of events at Newmarket Racecourse that includes race meetings followed by evening concerts were well attended and popular with people living in the home. Staff spoken with are enthusiastic about supporting people on community activities. The AQAA states that the home fosters good working relationships with family and other stakeholders to enhance people’s lifestyle. Records examined contain plenty of evidence that the home supports people to maintain good family links. Some people go home on a regular basis to spend time with families and other relatives visit regularly. Where distance makes it difficult for regular visits the home supports people to keep in touch by whatever method they prefer, such as by telephone or letter. Relatives who completed surveys confirmed that the home keeps them informed of things that are going on and they are involved in decision making where appropriate. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 14 As previously reported, the home continues to support people with their dayto-day routines in the way that they prefer, such as getting up and going to bed. The AQAA states that people have individual routines that meet their wishes and care plans examined confirm that people’s individual wishes and choices are supported. Observations on day of inspection visit show that people appear to enjoy the food. A tour of the premises confirms that a variety of nutritious food is available, including fresh fruit and vegetables. Records examined confirm that people’s specialist dietary needs are met and are well recorded. The home’s Quality Assurance surveys report that 95 of people living in the home are satisfied with meals. Wakes Hall DS0000017991.V349875.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, 20 and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using Wakes Hall receive excellent personal and healthcare support that meets their needs and wishes. The home has systems in place to ensure the safe administration of medication and the protection of people living there. EVIDENCE: On the day of the inspection, good practices were observed around how staff helped people with personal support. People are treated with respect and staff are aware of the need to maintain dignity. The AQAA states that care plans contain very comprehensive information, detailing exactly how each person wishes every aspect of their daily lives to be supported by staff. This gives clear directives to staff about the way they need to adjust their working practice to meet individual needs. Care plans examined contain sufficient detail to ensure that staff are able to meet people’s preferences about how they receive personal support. One person’s care plan contains details of the flash cards with photographs that the person uses for communication. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 16 A tour of the premises confirms technical aids and equipment they new overhead electric hoists have assistance with transfers have toilet/bathroom. that people living in the home have the need to promote their independence. Two been installed to ensure all those requiring one in their bedroom as well as the Care plans examined contain details of people’s needs around specific medical conditions. There is a range of health related documentation in place including nutritional records and weight records. A health-recording sheet gives details of appointments with relevant health professionals such as G.P., optician, physiotherapist, chiropodist and dentist. Staff files examined contain details of training around health related issues. Senior staff have received training around the administration of Epistatus for people with epilepsy, which was delivered by the clinical nurse specialist. There has also been training around management of constipation and epilepsy awareness. A visiting community nurse spoken with confirmed that district nursing services recognise there have been improvements in health care over time and they have no concerns about the care now being provided by the home. A survey completed by a G.P. said that “Wakes Hall are quick to recognise health problems and seek help appropriately” and “I have always been impressed by the support given”. Relatives commented that “the physical care is excellent” and “My relative has regular consultations”. Care plans examined contain details of prescribed medication, what it has been prescribed for and possible side effects. The AQAA states that all staff receive medication training during induction and are mentored and assessed by a senior member of staff before they can administer medication. Staff records examined confirm that staff receive training around the storage and administration of medication. As at the last inspection Medicine Administration Record (MAR) sheets are completed appropriately. Individual MAR sheets contain photographs to reduce the risk of errors in administration. The AQAA states that a robust system is in place for auditing the administration of medication and a reporting procedure is in place should any errors occur. Storage for medicines continues to be appropriate, with medicines kept in metal cabinets, which are securely locked. There is also a secure fridge for medication that needs to be stored at a controlled temperature, such as insulin. The AQAA states that care plans contain clear directives around people’s end of life wishes. Records examined all contain details of instructions in the event of serious illness, dying or unexpected death. Wakes Hall DS0000017991.V349875.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 good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. The home operates robust practices and procedures to protect the people who live there. EVIDENCE: The AQAA states that all staff receive training on the complaints procedure and literature is displayed throughout the home. The home follows the SCOPE complaints policy that is in place and a tour of the premises confirmed that copies of the policy are displayed around home. As previously reported the home ran a pilot programme providing training for people around empowerment. There are plans to follow up the empowerment programme with further training, which will focus on the ‘right to complain’ and the methods to do so. Completed surveys received from relatives of people living in the home confirm that they are aware of the procedure to follow if they have a complaint. As at last inspection homes processes for ensuring people are well protected are good. As previously reported, the home has policies and procedures in place around safeguarding people and there is a Whistle Blowing policy to ensure the protection of staff who may wish to disclose any issue of concern. A sample of records examined show that there are financial risk assessments in place to protect people who are unable to manage their finances. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 18 The manager is able to demonstrate a good awareness of her responsibilities around protecting vulnerable adults. Records examined show that staff have received Protection of Vulnerable Adults (POVA) training and the AQAA confirms that all staff receive annual refresher training around the adult protection procedure. Records examined confirm that staff have an appropriate Criminal Records Bureau (CRB) check. One protection issue was raised since the last inspection. The home managed the situation well, reporting the issue promptly and appropriately to all relevant parties. The outcome of the adult protection investigation that followed was that the allegations were not found to be substantiated and no further action is to be taken. Wakes Hall DS0000017991.V349875.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, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Wakes Hall benefit from a homely, comfortable environment that is well maintained and clean. The home has adaptations and equipment that meets the needs of the people living there. EVIDENCE: A tour of the premises confirmed that the home’s programme of refurbishment continues to build on last year’s Premises Improvement Plan. The AQAA stated that in the past year there has been extensive refurbishment of all toilets and bathrooms. The new bathrooms were seen to be refurbished to a high standard, ensuring a much-improved bathing experience for people living in the home. Although Wakes Hall is a large home, the furnishings contribute to the domestic and homely feel. The new carpets, blinds and furnishings that are in place are of good quality. Surveys completed as part of the home’s own Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 20 Quality Assurance process report a high level of satisfaction with the home environment. The AQAA states that specialist equipment and adaptations are in place where necessary and are reviewed regularly to ensure they continue to meet the needs of people living in the home. A tour of the premises confirms that the home provides adaptations to meet people’s needs. Everyone who lives in the home who requires the assistance of a hoist has electric overhead tracking in their individual rooms and further tracking is provided where necessary throughout the home. The general standard of cleanliness throughout the home is good. Records examined show that people are protected by the home’s processes around hygiene and control of infection. There are no odours throughout the home. The laundry room was refurbished at the time of the last inspection and is appropriate for the size of the home and the needs of people living there. Wakes Hall DS0000017991.V349875.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 good. This judgement has been made using available evidence including a visit to this service. People living in Wakes Hall benefit from a competent, well trained staff team, who are well supported and managed. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed. EVIDENCE: The AQAA states that 51 of the staff team has a National Vocational Qualification (NVQ) at level 2 or above, although this has increased since the information was sent to the Commission. The home now has four NVQ assessors to support staff undertaking the award. A discussion with the manager demonstrated a commitment to providing staff with qualifications and she stated that one way of retaining staff is to ensure they feel valued and receive good training. Records examined confirm that the home has an ongoing programme of NVQ training. Staff files examined are very well organised and contain all the information required to meet the National Minimum Standard including two written references and proof of identity. The AQAA states that the home operates a Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 22 recruitment procedure that ensures competent and suitable skilled staff are employed following appropriate checks. Records examined confirm that people living in the home are protected by a robust recruitment process. The home’s programme of training is good and makes the best use of SCOPE’s range of training. Staff records examined contain evidence of a comprehensive staff induction programme. The range of training provided includes Medication training, Moving and Handling, Protection, Fire Safety, Basic Food Hygiene and First Aid. A sample of staff personal development files was examined. Supervisions are carried out regularly and are well recorded. All files contain evidence of annual appraisal. The AQAA records that staff have regular monthly team meetings, management meetings and Health & Safety committee meetings. “This ensures that staff are well-informed, involved and take ownership of strategies to improve the service.” Minutes of meetings are well recorded. Staff spoken with feel well supported. Overall the home exceeds the National Minimum Standard around supervisions. Wakes Hall DS0000017991.V349875.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 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in Wakes Hall benefit from a home that is well managed. The culture of the home ensures that interests of people living there are central to the way the home is run. The health and safety of individuals living and working in the home is promoted and protected. EVIDENCE: As previously reported, the manager has obtained appropriate qualifications in both care and management, including NVQ level 4 Registered Managers Award and a Certificate in Management. Discussion with the manager confirms that she is able to demonstrate an excellent awareness of her responsibilities around managing the home. As part of a management restructuring programme throughout SCOPE’s services, the manager has recently successfully re-interviewed for her post. Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 24 The rigorous interview process was carried out by senior managers of the organisation and candidates had to deliver a presentation around financial, health, and quality outcomes for the home. The AQAA states the manager ensures her own knowledge and skills are continually updated. SCOPE sends comprehensive reports regularly to the Commission under Regulation 26. Notification of incidents under Regulation 37 are also received promptly and completed in ample detail. The manager keeps the Commission informed of incidents and how they are being dealt with. As previously reported the home has a well-developed Quality Assurance process in place. They use a variety of methods to obtain the views of people living in the home, relatives, health and other professionals. Surveys are distributed and there are committees and meetings run by and with people living in the home so that they can voice their opinions. The manager collates all the information gathered and put together a report and action plan for the home that takes people’s views into account. A copy of the Quality Action report was sent to us at the Commission and the cycle has begun again for the coming year. The AQAA states that the manager ensures the home has an effective Quality Assurance process and responds appropriately to the feedback received during the process. Records examined confirm that this is the case. The home’s Quality Assurance surveys record a high level of satisfaction with the service from people living there, with 100 satisfied with level of choice and control they have over their lives, 95 satisfied with meals, 84 satisfied with social, recreational and educational opportunities offered by the home and 79 satisfied with home environment. As at the last inspection, the home provides evidence that the health, safety and welfare of service users are promoted and protected. A sample of Health & Safety documentation was checked and show that water temperatures are checked weekly. Fire records examined confirm that fire fighting equipment is checked regularly and serviced annually, the fire alarm system is tested weekly and smoke detectors monthly, emergency lighting and fire doors are checked monthly. Wakes Hall DS0000017991.V349875.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 3 2 3 3 X 4 4 5 3 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 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 3 4 X 3 X X 4 X Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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.V349875.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI Wakes Hall DS0000017991.V349875.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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