Inspection on 20/06/06 for Waverley

This inspection was carried out on 20th June 2006.

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 05/12/05

Waverley 13/10/05

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 Kathryn Emmons Key Unannounced Inspection 20th June 2006 4:15 Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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.V300959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 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.V300959.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during an afternoon and early evening visit on a weekday. During the visit the manager Mrs Sara Gibson, was present and assisted the inspector through the inspection.. A total of 3 hours was spent inspecting the home. The inspector toured the home and spoke with the manager and the carer who was on duty. Eleven of the residents were spoken with and comment cards were received from all of the residents prior to the inspection. The main method of inspection used was called “case tracking” which involved selecting residents and tracking the care they receive through checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? Since the last inspection service users have had more opportunity to be involved in community activities. Ongoing training is in place and staff have been attending various courses such as first aid and safe guarding adults. The registered manger has now completed her registered managers award. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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.V300959.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents experience is that the home are clear on their needs and have systems in place to meet these needs. Provision of contracts and terms of residence provide residents with confidence that they can expect a level of ownership and control over the service they receive. EVIDENCE: Since the last inspection a new resident has been admitted to the service. It was clear from initial details obtained, regarding the resident that the manager had obtained an assessment regarding the resident and their abilities and aspirations had been developed into a goal orientated service user plan. The resident was spoken with and they confirmed that” all I said I wanted to do when I came here is happening”. Through case tracking it was evidenced that residents had contracts and terms and conditions of residence. The resident and the manager had signed these. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 6,7,9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that care plans reflect their assessed needs and aspirations. Residents live in an environment where they are empowered to make decisions regarding how they live their lives. Through risk assessments which residents have been involved with, they can be confident that they are being kept as safe as is possible which still having opportunities available to be as independent as possible. EVIDENCE: Residents spoken with were aware that they had care plans in place and they confirmed they had been involved in these being written and reviewed. Goals had been identified and were realistic for individual residents abilities. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 10 Three of the residents were clear on who their key worker was and made comments such as “I sit with my key worker and talk about what I have been doing and if I am still ok to go out by myself”. Through discussion with residents and reading care plans it was clear that staff worked with the residents to provide what support was necessary but also being mindful of empowering the resident to be as independent as possible. A couple of residents made comments such as “I tidy my own room as one day I might leave here and then I will need to look after myself. The staff are helping me to do that”. Another resident said “I get help with what I need help with” and “some things, the staff know I cant do so help me straightaway”. Risk assessments were in place for activities ranging from using the iron to accessing the community without supervision. Residents were aware these risk assessments were in place and had been involved in there production. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the activities and opportunities available to them. Positive actions are taken to provide opportunity for residents to have social inclusion in the local community. Residents are confident that they will be supported to maintained relationships and friendships with staff involvement when needed. The staff provide support for resident to take responsibility for them selves and others and this is undertaken in a valuing and supportive manner. Residents’ dietary preferences are catered for. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents living in the home range from 19 years of age to 72 years of age. Activities provided in the home are optional for all residents. Staff have attended training in Equality and Diversity to ensure they have a good understanding of people needs in respect of their age, culture and sexuality. Residents spoken to say that activities were wide ranging and examples were given such as a recent Harley motorbike visit, a trip to a horse sanctuary and a beach trip. Residents made positive comments regarding activities such as “I go to night classes and I also can chose to go to a disco on an evening”. One resident stated that they had a voluntary job in a local shop for a couple of days a week and 2 other residents said they were known in the local shops and community. Further evidence was seen to reflect the homes social inclusion in the local community. Residents said they were able to have friendships and maintain relationships. Two of the residents who live at the home are married, another resident said the home helped her stay in contact with her boyfriend by letter and telephone and would be supporting her by taking her to visit her boyfriend at the weekend. Another resident was seeing their relative every day for a week as they were in the local area on holiday. Another resident said ”I am helped to get on the bus to visit my friend” . Many of the residents have friends and relatives visit the home on a regular basis. Within care files there was evidence of residents receiving visitors to the home and contact they have had with people outside of the home. Residents gave examples of how they took responsibility for looking after themselves with examples such as tidying their rooms through to preparing meals and going shopping. One resident said, “I am given help to learn how to look after my self”. Another resident said “I have to behave better otherwise it upsets other people I live with, Andy and Jon (care staff) help me with this“. Residents made positive comments regarding the food the home provided. Residents are involved in choosing the menu and alternatives are always available. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with support, which is delivered in a dignified and valuing manner in accordance with their needs. Residents are satisfied with how their personal and health care needs are met. Medication arrangements are satisfactory and provide protection for residents. EVIDENCE: Residents said they received the help and support they required. During the visit to the home interactions were observered between staff and residents, residents were spoken to in an appropriate and valuing manner. Residents said they chose how to live in the home and staff gave them freedom to make decisions. Discussion with care staff evidenced the homes ethos of empowering the residents. Residents have access to all health care professionals and this was evidenced by speaking with residents, staff and viewing records within care plans. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 14 The home has a medication policy in place and all staff that administer medication have received training and updates. Only a few residents have medication and through risk assessment it is identified that all residents currently require support with taking their medication. The medications are kept securely and records provide a clear audit trail. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their concerns will be listened to and investigated. Residents are protected from potential abuse by the homes safeguarding adults procedure and staff training. EVIDENCE: Residents said they were satisfied that if they had any concerns these would be addressed. Residents said they could speak to any of the staff and were not concerned about raising issues. Residents spoke with staff on a daily basis and residents meetings are also held and minutes are maintained. Staff training records evidenced that all staff had been trained in dealing with complaints and had received Safeguarding Adults training and both of the courses were updated on a yearly basis. The home has a safeguarding adults procedure in place. One staff member spoken to was able to discuss the action they would take if they thought an abusive incident had occurred. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and comfortable environment. EVIDENCE: A tour of the premises was undertaken. All areas were clean and tidy and free from any obvious hazards. Resident are involved in assisting with cleaning tasks. They confirmed this was their choice. In addition to this a cleaner is also employed. All residents have a key to the home and to their individual bedrooms. Fiore safety equipment and signs were in place. Cleaning products which may be hazardous are stored in a locked area. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 32,34,35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A motivated and enthusiastic care staff team supports residents. Residents are protected by the homes robust recruitment procedures. Ongoing training and supervision sessions provide a trained and skilled workforce. EVIDENCE: Comprehensive records are maintained in respect of staff and volunteers employed at the home. It was evidenced that a robust recruitment and induction procedure was in place. Staff are supported in their job and through discussion it was evidenced that staff were clear on their job role and responsibilities. A comprehensive training programme is in place. All staff receive regular training in all mandatory subjects and any other courses they feel are relevant, such as managing aggressive behaviour. Supervision sessions are undertaken monthly and records are produced and signed by the staff involved. Regular staff meetings are held. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit and have confidence in the fair and inclusive leadership style of the manager. Residents are kept safe by the homes health and safety polices. A quality assurance system provides residents with evidence of an improving and evolving service. EVIDENCE: The homes registered manager and provider is Mrs Sara Gibson. Mrs Gibson is a qualified social worker and has many years experience of working with adults with learning disabilities. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 19 All of the residents spoken with made positive comments regarding Mrs Gibson such as “I love living here with Sara”, This is my home and Sara looks after me very well”, “I can tell Sara anything and she will sort it out for me”. Staff spoken with made comments such as “Sara is interested in hearing our opinions about the home”. The home has a quality assurance programme in place, which includes obtaining the views of relatives and visitors to the home. The system is being reviewed to extend the questionnaires to stakeholders such as social workers and staff who work at the day centres and colleges the residents attend. The deputy manager is responsible for maintaining all records in respect of health and safety issues. It was evident that training in fire safety and moving and handling was taking place regularly. All polices and procedures were available for staff to read. These are updated regularly. Residents gave examples of how they assisted in maintaining health and safety in the home such as “telling the staff is something looks dangerous” and making sure that “I tidy up after myself in the kitchen”. No obvious hazards were noted while touring the building. Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 4 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 4 13 4 14 x 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 3 x Waverley DS0000002471.V300959.R01.S.doc Version 5.2 Page 21 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.V300959.R01.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Waverley DS0000002471.V300959.R01.S.doc Version 5.2 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!