Inspection on 09/01/06 for Wapley Court Care Home

This inspection was carried out on 9th January 2006.

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 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

Wapley Court Care Home 17/05/06

Wapley Court Care Home 14/07/05

Wapley Court Care Home 15/02/05

Wapley Court Care Home 21/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Wapley Court Care Home Kelston Close Yate South Glos BS37 8SY Lead Inspector Paul Clark Announced Inspection 10:00 9 January 2006 th X10015.doc Version 1.40 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 Wapley Court Care Home DS0000035256.V257136.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 Older People. 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. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wapley Court Care Home Address Kelston Close Yate South Glos BS37 8SY 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) 01454 866840 01454 866841 South Gloucestershire Council Mrs Sally Diane Macauley Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate 32 service users aged 65 years and over requiring personal care only. 14 July 2005 Date of last inspection Brief Description of the Service: Wapley Court is a care home operated by South Gloucestershire Council. It is one of eight care homes operated by the Council. It is registered to provide personal care for up to thirty-two older persons who are aged sixty-five years and over. One of the places is kept for short-term care. The home is of a two-storey design set in its own grounds. It is located in a modern residential area, close to shops, pubs and other amenities. The home is close to a main bus route, with services running into Bristol City Centre. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an announced visit to Wapley Court by Paul Clark, Regulatory Inspector. On the day of the inspection the Inspector met twelve of the residents at present living in the Home. Several relatives were also spoken with. Comments Cards were also sent to relatives the majority of whom made very positive comments about the quality of care provided by the Home. Also spoken with at length was the Manager and staff. Staff were also observed going about their daily duties. A substantial number of resident’s bedrooms were seen as were the gardens. A selection of care records were viewed, as were the Home’s policies and procedures. What the service does well: 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. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5. The home is not registered to provide intermediate care. Wapley Court provides all the information necessary to help prospective residents make informed judgements about whether the Home would be right for them and encourages people to visit and try out the services they have on offer. Residents express a high degree of satisfaction about the care they receive. Assessments are comprehensive and kept up-to-date. The Home ensures that it offers placements only to those whose needs they can meet. EVIDENCE: Wapley Court’s Statement of Purpose clearly outlines how each prospective resident will spend a day at the Home to ensure that the environment is one that they would wish to live in. They may also stay overnight to further test the Home’s suitability if they so desire. A ‘Care Needs Assessment’ must be undertaken by the placing social worker before admission; three of these assessments were examined. The Home devises (over a period of from up to six weeks) a fuller Provider Service Delivery Plan. All admissions are on a four-week trial basis; at the end of this, a review meeting (attended by the resident and their families, their key worker and a member of the management team) is held to ensure that the resident wishes Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 8 to remain and to discuss whether the Home can truly meet that person’s needs. The Inspector examined the Home’s comprehensive Statement of Purpose and Resident’s Guide (“Welcome pack”), which were clear, concise and userfriendly. The Statement of Purpose outlines in detail the Home’s aims and objectives. It also includes organisational structures, complaint procedures, services that will be provided to residents and a synopsis of the level of need that the Home will cater for. Also included in the welcome pack was a copy of the local Resident’s Handbook, describing local services which is a nice way to help residents from outside of Yate to feel more a part of the community. Examples of the Statement of Terms for residents were seen – these covered such issues as what the fees do and do not cover and resident’s rights to speak to the CSCI in the case of any disputes. A copy of the contact details of the CSCI is also displayed on the back of every bedroom door. Evidence was seen that residents had been consulted over their admission to the Home and plans are always updated on a regular basis to reflect the changing needs of residents over time. The Service Delivery Plans seen by the Inspector clearly summarised how the assessed needs of residents would be met, including emotional, mental health and spiritual requirements. The Inspector spoke to twelve residents during this visit and a number of visiting relatives. All were very positive about the way that the Home provided care. Staff were seen to be speaking to residents in a friendly and caring way during the course of the visit. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Individual care plans are completed in a detailed fashion and regularly reviewed. Procedures for the storing and recording of the use of medication were in order. Access to health care is robustly maintained. EVIDENCE: The Home has a detailed care plan for each of the residents and the Inspector looked at a sample of three of them in some detail. There was evidence that each plan was properly constructed, reviewed and updated at least every six months. There is also an independent formal review carried out annually on each resident. Residents are consulted and made a party to any reviews of their plans. The Home has adopted a system whereby daily running reports and staff supervision sheets (where such supervision sheets deal with resident’s progress etc) all go towards updating care plans on a regular basis. Risk assessments for residents were in place which had also been updated regularly. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 10 The Home operated a key worker system and the Inspector was shown evidence of how an identified member of staff is made responsible for the overall care needs of a group of service users. Wapley Court’s Statement of Purpose outlines how they encourage independence for residents and aim to help those who may lack the motivation and insight to remain safe in the community. There is also an area in the home known as ‘The Flat’ where there are two bedrooms which are occupied by those residents whose care needs allow more independence. The Manager stated that residents were registered with four GP practices. Residents may retain their own GP on admission if they wish. A health record is maintained for each resident, these along with the accident records were examined and found to be in order. The procedure for the ordering, administration and disposal of surplus medication was reviewed and a sample of these administration charts for three residents were examined. The charts were in order and properly signed off. A photograph of each resident is attached to their medical sheet to ensure that the right medication is given to the right person. A chart outlining the requirement for medical standards is prominently displayed for staff guidance in the medical storage room. Medication is kept on a weekly basis so not a great deal of stock is kept; this is because the local pharmacy is just across the road. The Home’s storage and record of controlled drugs was in line with good practice. Residents praised care staff when spoken with and the Inspector witnessed both Managers and carers dealing with resident’s issues in a respectful and friendly manner. Telephone points were installed in every resident’s room; residents may pay for their own personal phone or use the portable payphone which is available. A ‘statement of rights’ is posted in the entrance hall and the Home’s Statement of Purpose outlines how Wapley Court aims to treat residents in a dignified and caring manner. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Routines in the Home are flexible and varied enough to allow residents a life style that can match their preferences. Contact with relatives and the local community is encouraged. Catering in the Home is very good, offering a wide range of appealing and nutritious menus. EVIDENCE: A list displayed in the entrance hall of the Home gave details of the activities that are available for residents both for the current and coming week. Two care assistants are responsible for organising internal activities (such as bingo, fish and chip suppers etc) and one looks after outside activities, visits etc. (a coach trip to the pantomime was planned for the 17 January). The Home does not have its own bus but uses community transport and local taxi firms which take South Gloucestershire travel tokens. This leads to the opportunity for more appropriate one-to-one sessions with residents than would be offered on larger coach trips. The Statement of Purpose mentions how friends and relatives are positively encouraged to visit the Home and are equally encouraged to assist with the general support of a resident. During the inspection, several relatives were visiting the Home; they told the Inspector that they were always made to feel welcome and that they had good relationships with the Manager and the staff. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 12 Links with the local community appear strong. Very close by are four schools; a nursery; infant; primary and a “special” school with which the Home has a great deal of contact. Some residents, for example go up to one school and help children with their reading. Residents were very positive about the food served at the Home. The Home has received a Food Safety Award for the 5th year running. The Cook keeps a record of any special diets and menus are planned some months in advance. The menus showed that a well-balanced and nutritious range of dishes were available. One small point was that the chopping boards were becoming rather scored and although these were kept scrupulously clean it is recommended that they be replaced. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Information is available for residents and their relatives which clearly advises them how to complain about any aspect of service provided at Wapley Court should they so wish. Residents are able to express any concerns they may have to the Homes Manager both formally and informally. Staff have received POVA training. Residents are able to exercise their rights to vote. EVIDENCE: The Inspector saw evidence on file that the Home has a complaints procedure in place which outlined how residents may complain about any aspect of the service they receive either informally or in a more formal way. Residents when spoken with by the Inspector confirmed that they would have no problem in approaching staff if they were dissatisfied about something. Information about complaints policies were displayed prominently on notice boards. The complaints log was also viewed and seen to be appropriately formatted. Residents voting registrations are in place. South Gloucestershire Council’s has its own POVA policy in which the majority of staff have received training in. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Wapley Court is well-kept and well-maintained, clean and tidy throughout. Decorations are to a high standard. Communal areas are well-furnished and equipped. Gardens are pleasantly landscaped and accessible to residents. The Home overall is safe and comfortable to live in. EVIDENCE: Wapley Court is a purpose-built property, set in a modern residential area of Yate. It is situated close to local shops and other amenities. The Home’s bedrooms are situated on the ground and first floors. An “independent-living” flat that was situated on the first floor has been converted to ordinary accommodation (but with a separate kitchenette), thereby increasing the Home’s capacity from 30 to 32 places. Those residents whose care needs allow are able to use these rooms with a greater degree of independence. It was noted that the kitchen cabinet in the kitchenette needs attention and it is recommended that this be done. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 15 The Home is set in it’s own very pleasant grounds. The gardens are well maintained (mostly by the Home’s staff) and contain several patio sets, gazebos etc where the residents are free to sit whenever they choose to do so. Part of the garden is close to a public footpath enabling residents to converse easily with passers-by should they so wish. There are four separate lounges provided. The Inspector spoke with many of the residents in their communal rooms; residents appeared comfortable and at ease with their surroundings. The dining area is situated off the main entrance. Some residents prefer to sit there during the day and spread out a little in the extra space available. A smoking room (used by the residents and staff) is situated on the first floor. Each resident has a bedroom for their individual use, many of which were viewed by the Inspector. Residents may bring their own fixtures and fittings that are deemed suitable into their rooms, plus personal possessions such as photographs etc. Each room has a wash-hand basin; toilets and bathrooms are situated close to bedrooms and public areas. Bathrooms and toilets were scrupulously clean and odour free. Adaptations for disabled people were in place, including bath hoists and standing aids. It was noted that the enamel on the bath in the 1st floor bathroom is badly chipped and should be attended to. It was also noted that the temperature of the hot water at bathrooms and hand basins was in excess of recommended levels. This was brought to the attention of the Registered Manager and it is required that this is routinely checked. All rooms are centrally heated and radiators are covered with protective guards. The Home, being purposely built, is well laid out and spacious. Grab rails were in place in suitable locations, such as the lavatories. Each bedroom is equipped with a call bell, as are communal areas. During the inspection, domestic staff were working diligently throughout the Home. Overall, the Home was very clean and well kept. Separate laundry services were in place. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Wapley Court is adequately staffed by a mix of fully-trained and other staff to meet the assessed needs of residents. Recruitment practices are based on equal opportunities principles and ensure residents protection. EVIDENCE: The Manager looked at the Home’s detailed and legibly completed staff duty records for both managers and care staff. There are a minimum of three care staff on duty as well as at least one manager working during the day with extra staff available at busy periods. The Manager shared with the Inspector the Home’s NVQ action plan for staff. eight staff are now qualified at NVQ Level 2. Three NVQ assessors are on the staff of the Home. The Home operates a robust procedure with staff recruitment, based on South Gloucestershire Council’s equal opportunities policies. A comprehensive staff induction checklist is in place. Individual staff supervision frequencies are appropriate. Team meetings are held regularly. Separate meetings are held for cooks, managers, domestic and care staff. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 Managers at Wapley Court are experienced and well-trained. Good systems of administration are in place. Residents financial interests are looked after. Health and safety procedures in the Home are generally satisfactory. EVIDENCE: The management team at Wapley Court consist of the Registered Manager and three full-time duty managers, all of whom, as the Home’s Statement of Purpose outlines, have many years of experiences between them. The Registered Manager has nearly completed NVQ Level 4 in Management, holds a Registered Manager’s award and holds a nursing qualification for working with those with learning difficulties. Discussion with staff confirmed that they had been encouraged to give their opinions and suggestions about the running of the Home. Evidence of regular residents’ meetings was also seen. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 18 An external quality assurance system is in place. The organisation collates all material for analysis and comment including independently constructed and distributed questionnaires for staff and residents. The Home’s administrator showed the Inspector the Home’s system for handling resident’s finances. Residents sign for any money that is withdrawn. Receipts were in place for items bought by or on behalf of residents. Computerised accounts of all transactions are sent to the Home each month from South Gloucestershire head quarters. Residents’ records are kept securely locked away in filing cabinets in the Home’s office, but are never the less available to staff if they should need them. All records seen by the Inspector were legible and kept up-to-date. Records of fire alarm inspections and weekly tests by staff were seen and were in order, as were service certificates for lifts, hoists etc. Fire drills had been carried out during the required period. However, it was noted that fire records are kept in several different record books and it is recommended that these be kept in one, dedicated record book. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 20 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 OP21 Regulation 23 Requirement The temperature of the hot water at bathrooms and hand basins was in excess of recommended levels. It is required that this is routinely checked. Timescale for action 09/01/06 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 2 3 Refer to Standard OP15 OP19 OP19 Good Practice Recommendations It is recommended that the kitchen chopping boards be replaced. It is recommended that the kitchen cabinet in the kitchenette (in the area known as ‘the flat’) be attended to. It was noted that the enamel on bath in the 1st floor bathroom is badly chipped and should be attended to. Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Wapley Court Care Home DS0000035256.V257136.R01.S.doc Version 5.0 Page 22 - 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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