Inspection on 06/06/06 for Wavelly House

This inspection was carried out on 6th June 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wavelly House 12/12/08

Wavelly House 08/11/05

Wavelly House 20/12/04

Wavelly House 08/06/04

Wavelly House 20/03/04

Wavelly House 23/06/03

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 7a Wavell Road Basingstoke Hampshire RG22 6EQ Lead Inspector Craig Willis Unannounced Inspection 6th June 2006 09:30 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 7a Wavell Road Address Basingstoke Hampshire RG22 6EQ 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) 01256 333 773 www.together-uk.org Together Working for Wellbeing Miss Jessica Neighbour Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: 7a Wavell Road provides care and support for people with mental health issues. Together Working for Wellbeing is the registered provider. The home currently has an acting manager whilst the provider is recruiting to the post permanently. Help is given with personal care and daily living needs when required as well as supporting people to maintain their independence. It is a large home set in a quiet road in Basingstoke, which is a bus ride to the town centre. There are six single bedrooms as well as a smoking area and a lounge/diner. There is also a well maintained garden for service users. The manager reported on 9th June 2006 that the weekly fee for a place in the home is £823.07 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) and a site visit to the home on 6th and 7th June 2006. During the site visit the inspector spoke with three of the service users, staff on duty and the manager. A tour of the communal areas of the building was made and the inspector observed the way staff were supporting service users. Documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? The home’s policies and procedures have been updated to reflect the new name of the provider. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 6 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. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of service users before they move into the home. EVIDENCE: No service users have moved into the home since the last inspection. The records of four service users were inspected during the visit. A needs assessment had been completed for each of these service users before they moved into the home. This assessment included details of the support that they need when they are mentally unwell, the spiritual and cultural needs of the service user and the support that was needed for service users to develop their independence. Copies of the care plans agreed through the Care Programme Approach are available for service users. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of service users are well met through the home’s care planning and risk assessment systems. EVIDENCE: The files of four service users were inspected during the visit. Each service user had a set of care plans that had been developed from their needs assessment. These plans set out how the needs of service users should be met and had been reviewed monthly. Where the needs of service users have changed, amendments have been made to the plans. Service users have signed the plans. Service users spoken with said they were aware of the contents of their plans and felt they gave accurate information. Details of how service users make decisions are included in the care plans. Daily records demonstrate the support staff have provided to help service users make decisions, setting out the various options and consequences. Restrictions on service users, for example on smoking and the use of alcohol, are clearly set out in care planning documents and service users have signed to say they agree to follow them. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 10 Risk assessments have been completed for service users, setting out the hazards to service users and the actions that should be taken to minimise the risk of harm. These assessments are reviewed regularly and have been amended as a result of incidents to service users or changes in their support needs. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support to meet the lifestyle needs of service users, including suitable activities, appropriate relationships and good meals that offer variety and choice. The rights and responsibilities of service users are recognised. EVIDENCE: Service users are encouraged to take part in activities within their local community and details of events are displayed on the notice board in the hallway. Service users spoken with said they liked to go out to local shops, betting shops, pubs and car boot sales. Leaflets from local political groups were available for service users in the hallway. Support is provided for service users to maintain contact with family and friends through letter, e-mail and personal visits. Service users spoken with said they were able to see who they liked and are able to see visitors in private. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 12 Service users have a key to the front door and their bedroom and have unrestricted access to the communal areas of the home. Staff were observed interacting with service users in a friendly and respectful manner during the visit. Details of the support service users need to take part in household jobs such as cleaning and cooking are set out in their care plans. The home has a planned menu, which provides a varied and balanced diet. There is a choice of two meals and service users spoken with said the food was good. Some service users are supported to do their own shopping for breakfast and snacks, to develop their independent living skills. Details of the support they require to do this are included in their care plans. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of service users are well met by the way staff provide support and access to health services. The home has good systems for administering regular medication, although more detail is needed in procedures for administering ‘as required’ medication, to ensure that service users are kept safe. EVIDENCE: Service users spoken with said that staff treat them well and provide support in the way that they want it. Details of the personal care support that is needed are set out in service users’ care plans. Service users are supported to access a wide range of health services, including GP, community psychiatric nurse, psychiatrist, dentist, optician and hospital outpatient appointments. Service users spoken with said they were able to see their doctor when they needed to. Records were kept of appointments, including any advice that is given by the practitioner. Details of when service users have been advised to seek medical advice and have refused are recorded in the daily records. Medication is stored in a locked cabinet in the office and medication administration records were fully completed. Staff administering medication have received training and one member of staff confirmed that staff do not administer medication until they have completed the training. Following an 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 14 assessment of their needs, one service user is administering their own medication. Staff reported that this service user has a locked medication cabinet in their bedroom. The home has general guidance on how service users should be supported to take ‘as required’ medication, which involves two members of staff and the service user making the decision. The manager reported that there are times when service users do not think they need the medication, although staff make a judgement that it is necessary, and give this advice to the service user. The manager agreed that it was necessary to have individual guidance for each service user, which sets out the criteria that staff should use when making this judgement. The guidance should be developed in conjunction with the health team working with the service user. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to deal with concerns and complaints and to protect service users from abuse. EVIDENCE: The home has a complaints procedure, which has been supplied to all service users. The procedure includes details of who would investigate a complaint and the time within which a complainant would receive a response. Service users spoken with said that they were confident that any complaint they made would be taken seriously by staff and action taken to resolve the problem. The complaints record was inspected and no complaints have been received since the last inspection. All staff have completed adult protection training and staff spoken with demonstrated a good understanding of abuse and action they should take if abuse is reported or suspected. The home has an adult protection policy and a copy of the local authority adult protection procedure. The home looks after the money of two service users, which is checked daily and records and receipts are maintained of transactions. The money for these two service users was checked during the visit and found to correspond with the records. The money is individually stored in the safe. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 16 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a safe, homely environment for service users. EVIDENCE: The home is well maintained and was clean on the day of the visit. Service users spoken with said that they had all that they needed in their bedrooms and the communal space and that the home was kept clean and well maintained at all times. The home had good quality, domestic furniture and the premises are in keeping with the local community. The home is situated within 200 metres of local bus services, which provide transport into Basingstoke town centre. The manager reported that there was a maintenance agreement with the housing association that owns the building and there are no outstanding maintenance issues. There is a separate laundry room, which does not require laundry to be taken through food preparation or storage areas. Hand washing facilities are provided throughout the home, including in the laundry room, toilets and kitchen. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are provided with a comprehensive training programme and service users are confident staff have the skills to meet their needs. The home operates robust recruitment procedures, which help to protect service users. EVIDENCE: The manager reported that of the seven staff, three have achieved the NVQ level three in promoting independence, one is working towards the qualification and two are due to start it in September 2006. Staff spoken with said they were enjoying completing the NVQ and felt they got good support from the organisation to undertake the qualification. The manager reported that no staff had been recruited since the last inspection in November 2005. The recruitment records of the last two staff to be employed were inspected during the visit and were found to contain evidence that the home had obtained written references and an enhanced disclosure from the Criminal Records Bureau before they started work. The manager reported that at the last set of recruitment interviews, one of the service users was a member of the panel and asked questions that they had devised. Staff complete the Skills for Care Induction and Foundation programmes and have completed additional training in first aid, medication, mental health legislation, the recovery model of mental health, drug and alcohol awareness, 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 18 hearing voices, violence and aggression, adult protection, risk assessment, fire safety, moving and handling and food hygiene. Service users spoken with said that they thought staff had the right skills to meet their needs. Staff spoken with said they thought the organisation provided excellent training and there are no courses they feel they need that they’re not able to access. 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by a competent manager who takes action to promote the health, safety and welfare of service users and staff. The appointment of a permanent manager will help to ensure that the service continues to develop. EVIDENCE: The home currently has an acting manager, who reported that the organisation was planning to recruit to the post permanently by August 2006. The manager said she has completed the NVQ level four in care and is currently completing the Registered Manager’s Award. The manager reported that she is receiving good support from the senior managers of the organisation whilst covering the position. Staff spoken with reported that since the last inspection the home’s policies and procedures have been updated to reflect the new name of the provider. The policies and procedures were not inspected on this visit. The organisation sends questionnaires to service users and their family, GPs, community psychiatric nurses and other members of the health team involved 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 20 in the service as part of an annual review of the quality of the service provided. The information gathered is collated and used to develop a plan to further improve the service provided. The information is presented to service users and other stakeholders at an event outside the home where there is the opportunity to put questions to the manager and area manager. The area manager visits the home every month to complete a ‘service monitoring report’, which involves checking the performance of the service. These reports have actions on them where the area manager feels improvement is required and the actions are checked at the following visit. Monthly meeting are held for service users, enabling them to ask questions and have a say in the way the home is run. Regular tests are made of the fire alarm system and equipment and the system and extinguishers were serviced in March 2006. Staff have received fire safety training. The electrical wiring was checked in 2003 and portable electrical appliances are tested annually. The gas boiler was serviced in August 2005 and the hoist was serviced in January 2006. Assessments are completed of chemicals used in the home and they are stored in locked cupboards 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 21 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 4 X X 3 X 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 22 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. 1 Standard YA20 Regulation 13 (2) Requirement The registered person must ensure that individual guidelines are developed for service users who take “as required” medication. Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 7a Wavell Road DS0000012307.V291001.R01.S.doc Version 5.1 Page 24 - 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. 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