Inspection on 09/11/05 for Wakes Hall

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also 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 21/02/06

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 Steve Boyd Unannounced Inspection 9th November 2005 09:30 Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 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.V269722.R01.S.doc Version 5.0 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.V269722.R01.S.doc Version 5.0 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.V269722.R01.S.doc Version 5.0 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 21st December 2004 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.V269722.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during one day in November 2005. The inspector spoke with a number of service users and staff during the inspection and observed interactions between them. Discussion also took place with the manager, Mrs Irvine. A tour of the premises was undertaken and various records and policies were perused. Sixteen out of twenty Standards assessed during the inspection were found to be met. What the service does well: What has improved since the last inspection? What they could do better: As with any home the size of Wakes Hall, continuous work and improvements on the premises are always needed and some more pressing areas are highlighted under the Environment section of this report, such as the need to refurbish some bathrooms and redecorate the activity centre kitchen. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 6 Scope’s organisational directive in relation to supporting service users abroad, highlighted staff members were unable to provide this input due to insurance issues. Currently this directive is being looked into by the CSCI. 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.V269722.R01.S.doc Version 5.0 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.V269722.R01.S.doc Version 5.0 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): 2. Prospective service users have their needs and aspirations assessed in a holistic manner. EVIDENCE: Pre-admission and ongoing assessments were seen to be available for both new and existing service users that took a holistic approach to their care needs. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 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): 6 and 9. Service users’ records sampled were found to have individual plans of care in which they were involved in drawing up. Service users are supported to take risks in their day to day lives. EVIDENCE: The home has put in place a new care plan format since April 2005. Samples of these care plans were seen for a number of service users and were found to contain clear objectives and how these could be met. It was clear that the care plans were drawn up with service users’ involvement. Plans were easy to read and were seen to be reviewed on a periodic basis. Risk assessments were seen to be available for service users covering both potential risks within the home and those that may occur outside of the home. Strategies to deal with and minimise potential risks were in place. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 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): 12, 14 16 and 17. Service users were clearly able to take part in appropriate activities inside and outside of the home. A wide range of leisure activities are available to service users. Holidays for service users are supported by staff. An organisational directive is currently being investigated to enable service users to receive support from the immediate staff team when travelling abroad. Service users were respected by staff. Healthy and enjoyable meals were available for service users in the home. EVIDENCE: The home has its own activity centre where a range of activities is available to service users, such as craft and art work and the use of computers. Also, a number of tutors come into the activity centre to run various sessions with service users related to education and life skills activities. Service users engage in a range of leisure activities away from the home including trampolining, swimming and horse riding. The home has its own cinema room and a therapy room which are both enjoyed by service users. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 11 One issue reported by the manager, a team leader and a service user to the inspector was that of accessing holidays abroad. Although service users can go on holiday abroad, this has to be with staff from enabling agencies rather than the home’s own staff as there is an apparent problem with covering staff for business use whilst out of the country. As many service users prefer to go abroad with people they know and who know their care needs, this effectively is seen to reduce service users’ opportunities to go on holidays outside of Britain. Service users’ interaction with staff during the inspection was seen to be very good. Staff were seen to show respect and promote dignity for service users. Service users able to comment were positive about the quality and quantity of food on offer at the home. Menus were seen which showed choice and variety. A lunchtime meal was observed in one unit and was seen to be a relaxed and unhurried occasion. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Service users’ health needs were being met and they were protected by the home’s policies and procedures dealing with medicines. EVIDENCE: Individual records for service users, including their care plans, indicated that their physical and emotional health needs were assessed, acted upon and reviewed when necessary. At the time of inspection the home was operating a monitored dosage system of medicine administration which was seen to be working effectively. Medicines were kept in a safe and secure manner; administration records were seen to be up to date and staff who administered medicines were trained. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service users’ views are listened to and acted upon where necessary. The home’s policies and procedures for protecting service users from abuse, neglect and self harm were working well at the time of inspection. EVIDENCE: The manager, Mrs Irvine, advised the inspector that no complaints had been received by the home since the previous inspection. Service users spoken with during the inspection did not raise any concerns or complaints about the operation of the home. The home had suitable complaints policies and procedures in place. The home had an adult protection policy and procedures in place for use if necessary. The protection of vulnerable adults is an area covered by Scope in its training initiatives for staff. The inspector was advised that no protection of vulnerable adults’ issues had arisen since the previous inspection. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30. Generally service users live in a homely, comfortable and safe environment. Service users’ bathrooms would benefit from some refurbishment. The home was found to be clean and hygienic. EVIDENCE: Service users’ individual rooms and communal areas were found to be furnished and decorated in homely styles. No obvious safety hazards to be found throughout the inspection. As with all larger homes, ongoing refurbishment and redecoration needs to take place, and the inspector’s opinion was that the laundry area in the main building would benefit from redecoration, as would the activity centre kitchen. The corridor leading to the therapy/snoozelum room would also benefit from redecoration and reflooring. Some of the bathrooms in the main building appeared in need of refurbishment and redecoration, e.g. the “pink” coloured bathroom on the ground floor of the main building. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 15 The home was found to be clean and free from any offensive odours during the inspection. Service users’ indicated their rooms were kept in a clean and tidy manner. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 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): 32, 34 and 35. Service users were found to be supported by both confident and qualified staff. The home’s recruitment policies and practices support and protect service users. Service users’ needs are met by suitably trained staff. EVIDENCE: Since the previous inspection the home has now achieved more than 50 of care staff being qualified to National Vocational Qualifications at Level 2 or above. Also, a significant number of staff are working towards achieving Learning Disability Award Framework qualifications. Staff spoken with during the inspection presented as confident and knowledgeable about service users. One issue which needs to be reviewed regarding the staffing situation is the fact that one team leader post has been frozen since the last inspection, meaning that the management team has effectively been reduced from three to two. Although the inspector did not find evidence that this was compromising the quality of care and leadership in the home, concerns were Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 17 expressed that the development of the service and delivery of an effective operation could be compromised if the situation is not resolved. Staff records indicated that the home’s recruitment policies and practices supported and protected service users. Evidence was seen of application forms being completed, reference and CRB checks being undertaken and photographic identity being provided for new members of staff. The inspector found good training records being kept by the home. Since the previous inspection training on many individual areas to complement the NVQ and LADF training has taken place. This included training on protection of vulnerable adults, moving and handling, medication, food hygiene, fire safety and disability awareness. There is an ongoing training plan and each staff member has individual records kept of training that has been undertaken by them. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 18 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, 39 and 42. Service uses benefit from a well run home. A quality assurance system is in place which puts service users’ views at its heart. The health, safety and welfare of service users are promoted and protected by the home’s policies and procedures. EVIDENCE: The home’s manager, Mrs Irvine, is well qualified and experienced. She has a diploma in management and is currently undertaking the Registered Managers Award. The home was found to have a quality assurance policy and process. A new annual cycle of surveying service users and significant others, auditing and action planning was in progress at the time of inspection. Some changes had been made to the manner of seeking service users’ views to make it easier and Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 19 more meaningful. The action plan derived from the previous cycle of monitoring had been addressed. Safety certificates were seen to be available for various equipment and systems within the home, e.g. fire safety. COSH assessments had been undertaken as well as other risk assessments within the home. Policies and procedures for health and safety were seen. First aid training had been undertaken by a number of staff, as well as training in food hygiene, fire safety and moving and handling. No obvious safety hazards were seen during the course of inspection. Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wakes Hall Score X 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 X DS0000017991.V269722.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 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 person must ensure that the manager is qualified to NVQ Level 4 in Management and Care. This is a repeat requirement. Timescale for action 31/03/06 2. YA27YA24 13 31/03/06 3 YA37 9 (2)(i) 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wakes Hall DS0000017991.V269722.R01.S.doc Version 5.0 Page 22 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.V269722.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!