Inspection on 13/10/05 for Waverley

This inspection was carried out on 13th October 2005.

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

Waverley 20/06/06

Waverley 05/12/05

Waverley 02/03/05

Waverley 04/11/04

Waverley 26/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Waverley 164 High Street Mablethorpe Lincs LN12 1EJ Lead Inspector Roger Harrison Unannounced Inspection 13th October 2005 09:00 Waverley DS0000002471.V257028.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 Waverley DS0000002471.V257028.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. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waverley Address 164 High Street Mablethorpe Lincs LN12 1EJ 01507 473071 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) waverley.res-home@virgin.net Mrs Sara Georgina Gibson Mrs Sara Georgina Gibson Care Home 13 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (1) of places Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: Waverley provides personal care and accommodation for up to 13 service users. 12 places are for adults who are admitted within the category LD – Learning Disability up to the age of 65. The other registered bed is registered to accommodate a service user over 65 years of age. The home is a two story residential property situated in the main area of Mablethorpe town centre. The home has a minibus and this is used to transport service users to day centres and trips out. Car Parking in provided on the roadside and a couple of spaces are available on the front driveway. To the side and back of the home there are lawned areas and flower beds. Mrs Gibson is the registered provider and is also the registered manager. The homes statement of purpose makes reference to aiming to provide a lifestyle for service users that meets all their personal, social, cultural, religious and recreational needs and interests. A focus is placed on supporting service users to exercise freedom and control over their lives. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over a four and a half-hour period, with the inspector using a method of inspection called “case tracking”. This involved selecting three residents who currently live at the home and tracking their experience of the care and support they have received during the time they have lived at the home. This was achieved by the inspector talking to the manager, touring the home, looking at information on care plans and files, talking to residents and care staff, and observing day-to-day care practice within the home. What the service does well: What has improved since the last inspection? Care provision remains consistent with the last inspection. There were no requirements or practice recommendations made. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 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. Waverley DS0000002471.V257028.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 Waverley DS0000002471.V257028.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): 1 and 2. Detailed assessments are carried out together with any new resident by the manager and senior care team prior to any admission taking place. Residents and their family carers are given the written and verbal information needed to enable them to make an informed choice about moving to Waverley Care Home. EVIDENCE: The manager confirmed that a pre assessment is always undertaken covering all social and physical day-to-day needs. Consideration of existing residents re is taken into account in order to match existing care plans together with new residents needs and wishes to provide consistency of care for those already living at Waverley care home. The home has a statement of purpose and resident guide, which is discussed and shared with any new resident at the time of assessment. Written information provided to residents and their family carers is clear and sets out the main features of the home, the care levels that are provided and the facilities available. Information gathered at the pre assessment is used to complete a care plan, which includes all physical and social needs of the individual. These plans are reviewed on a regular basis so that any change in Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 9 need can be addressed. The care team were seen to take a great deal of time using a variety of methods for communicating with residents to provide the right level of support needed in order to maintain individual identity, independence and choice. Residents have their own key workers who were observed to be providing high levels of support and an understanding of each persons need throughout the inspection, which was reflected in written care plans for residents. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. The manager and care team encourage residents to make informed choices, supporting individuals right to take risks with support when this is needed. Care plans are reviewed to ensure changes in need and goals are acted upon. EVIDENCE: The home has a good relationship with health and social care support services in the community. Care plans looked at show that reviews of existing plans involve family and other professionals wherever possible in order to ensure residents changing needs are recognised and acted upon. Care plans also showed that assessments made at the time of admission had been reviewed as appropriate, to include risk assessments, which take account of residents wider needs and wishes. Care plans provided evidence of good Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 11 communication between staff and residents, and the freedom for individuals to make choices, for example; regarding how they would like to furnish their rooms, maintaining independence wherever possible with personal hygiene, how they would like to dress, the type of meals each enjoys and activities inside the home and in the wider community. The home provides regular holidays for residents, which are planned through full discussion and involvement of all residents, and, where appropriate their families. The manager described how holidays are used to develop decisionmaking and independence for residents. During the inspection two family carers told the inspector that; “They are really go-ahead here, and have done a brilliant job in providing care for our son”. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Residents are supported to take part in appropriate activities within the home and community. Residents are encouraged to maintain family relationships and to develop relationships with others with support as they wish. The home provides a varied and balanced nutritious diet for residents. EVIDENCE: Residents care plans evidenced appropriate risk assessments, with a clear link between risks highlighted on assessment documentation and the day-to-day care plan framework. The home has a clear missing persons policies and individual service users have agreements in place in relation to personal safety. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 13 All residents have a day package individualised to meet their needs. On the day of inspection, some residents were going out for the day and several were coming and going freely or going out later to various activities. Discussions with residents and family carers visiting on the day of inspection evidenced that they are encouraged to participate in local community activities and utilise local resources. Discussions with several residents confirmed that the care team encourages the appropriate development of relationships within the home and wider community, which increases confidence and the ability for residents to develop skills in interacting with others. Residents highlighted satisfaction with activities available at the home and opportunities they have to pursue leisure activities such as; swimming and bowling, which are done on a weekly basis. All residents spend one day working on a farm where they have individually adopted a horse. Residents were enthusiastic about the day they spend at the farm looking after their horse. The home has an activities room, which was being used by residents to practice life skills and other more creative tasks. Residents were keen to show the inspector work they had completed, including painting, weaving and knitting and confirmed that they lead a very active life. Breakfast and lunchtime was observed to be unhurried and relaxed. Residents were encouraged to eat in the dining room and utilise the time to chat with each other and the staff on duty. Residents told the inspector that the food is good, that there is always a choice and plenty of food available as and when required. All residents are able to eat their meals independently. The kitchen was clean and tidy and records were in place to evidence that all areas are monitored appropriately. Resident’s plans seen highlighted nutritional assessments. Menus were in place and these had been compiled through consultation with residents. Residents were very eager to show the inspector their rooms and three residents gave the inspector a guided tour, highlighting personal items of furniture and equipment. Rooms have been individualised were unique in design and décor. Residents are encouraged to maintain their rooms independently and are supported to do there own washing. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Residents are protected by policies and procedures within the home, which are used to ensure health needs, are met in the right way and to understand wider needs in order to encourage choice and self-determination wherever possible for each individual. EVIDENCE: Residents are encouraged to self medicate wherever possible. However, on the day of inspection all residents required support with medication. The home operates a monitored twenty-eight day dosage system, using appropriate lockable storage to maintain the safety of residents. Individual medication is assessed and reviewed on a regular basis. A random inspection of resident’s medication records provided good evidence of appropriate record keeping and signatures to confirm medication administration. All staff administrating medication have received appropriate training. Residents told the inspector that they were happy to receive support from the care team with their physical and social needs. One resident told the inspector, “My Key worker supports me to do as much as I can for myself, I am new here but would give this home give this home ten out of ten” Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 15 Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 16 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. Residents and family carers are encouraged to be open about their feelings and concerns. The manager and staff take action to address ideas put forward for developing practice and issues of concern. The home uses induction, training and team meetings to ensure that the policy in place for protecting residents is taken seriously and acted upon when required. EVIDENCE: The home has a detailed adult protection policy and a copy of Lincolnshire’s Adult Protection Committee Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults in Lincolnshire. The manager confirmed that an external trainer is used to update existing and new staff on the importance of protecting residents from abuse of any kind. The home has not needed to invoke the adult protection procedures, but the manager and staff team are aware of the protocols as required. Residents meetings are held and family carers are consulted as appropriate as part of the process in place for monitoring quality and performance. During the inspection residents and family carers visiting the home said that they felt their views are heard and acted upon and that any concerns raised were dealt with as they arose. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 17 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. The home is well maintained, clean and provides a supportive environment for all residents. EVIDENCE: The location and layout of Waverley is suitable for the purpose it serves. The home is a detached property located on one of the main roads into Mablethorpe Town Centre and is in walking distance from local amenities including shops, pubs and the seaside. Residents told the inspector they were extremely happy with the environment and expressed satisfaction of their own bedrooms. Residents were also eager for the inspector to see their rooms and several said they were extremely happy living at Waverley. On the day of inspection, the home was found to be generally clean and tidy. Records, discussions and observation made during the inspection indicate that the care home is generally safe and well maintained. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 18 Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 19 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): 32,34,35 and 36. The manager has robust recruitment procedures in place and provides appropriate levels of support to the care team, who are able to use training provided to support residents within the home and wider community. EVIDENCE: The manager confirmed that a robust recruitment policy and procedure is in place to ensure that the team is balanced and provides appropriate support for all residents safely. Residents are involved in staff interviews, which enables opportunities for joint discussion regarding the matching of residents needs with the staff team. All staff are trained to either NVQ level two or three and the inspector observed a training plan is in place for the year covering a range of appropriate courses and training days for all team members. Care staff told the inspector they are clear about their roles within the home and that they feel well supported by the manager. Supervision is provided formally each month for all staff with records maintained and stored securely by the manager. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 20 Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 21 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.. The home has a competent and committed manager and deputy manager who understand the needs of each individual resident. Residents benefit from the support given to staff by the manager to enable opportunities for appropriate training, the results of which help to maintain residents at the centre of the care giving, review and development process. EVIDENCE: The manager has been registered to manage the home since nineteen ninety three and confirmed that she has undertaken an NVQ 4 in Management, and is commencing appropriate training to enable existing skills to be developed further. The manager has an open, approachable style, which encourages residents and staff to raise ideas for developing services within the home. The Manager regards residents social and physical needs as central to the culture within the home and seeks their views regarding developments or concerns at Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 22 all times. A group of residents spoke with the inspector and said that “This is our home, we love living here and the manager is brilliant”, the home offers a safe and secure environment for residents, visitors and staff alike. Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 23 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 3 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 4 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Waverley Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 4 X 3 X X X X DS0000002471.V257028.R01.S.doc Version 5.0 Page 24 NO. 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. 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 Waverley DS0000002471.V257028.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. 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