Inspection on 05/12/05 for Waverley

This inspection was carried out on 5th December 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 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 Roger Harrison Unannounced Inspection 5th December 2005 09:30 Waverley DS0000002471.V268367.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.V268367.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.V268367.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.V268367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 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 is provided on the roadside and there are also spaces available on the front driveway. To the side and back of the home additional parking spaces have been added by the home owner. This work has been undertaken sensitively to enable greater access for visitors whilst complimenting the lawned areas and flowerbeds that surround the building. 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.V268367.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-hour period, with the inspector using a method of inspection called “case tracking”. This involved selecting two 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 deputy Manager, touring the home, looking at information on care plans and files, talking to residents and care staff, and observing care practice within the home. 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. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 6 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.V268367.R01.S.doc Version 5.0 Page 7 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): Outcomes not looked at. The key standards were looked at during the last inspection undertaken on 13/10/05. EVIDENCE: Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 8 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. Care plans are reviewed to ensure changes in need and goals are acted upon. The manager and care team encourage residents to make informed choices, supporting individuals right to take risks with support when this is needed. 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. Since the last inspection the Manager and care team have worked with residents to develop a procedure for signing in and out of the building. This process has incorporated the varied interests of individuals, who have chosen, and made symbols for communication that they recognise as their own. This system is supported by the homes missing person’s policy, and individual service users have agreements in place in Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 9 relation to personal safety. Care plans provided evidence of good 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. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 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: All residents have a day package individualised to meet their needs linked to Skegness College and community out reach resources. On the day of inspection, residents were going out for the day to various activities. Discussions with residents on the morning of the inspection evidenced that they are encouraged to participate in local community activities and utilise local resources. Discussions with two residents who were going out for the day 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 Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 11 satisfaction with activities available at the home and opportunities they have to pursue leisure activities alongside the more focussed activities that each resident undertakes, which are done on a weekly basis. All residents spend one day working on a farm where they have individually adopted a horse. Residents are enthusiastic about the day they spend at the farm looking after their horse. The home has an activities room, which is used by residents to practice life skills and other more creative tasks. The activity room has a full range of artwork and crafts on the walls and in within the room, which have been completed by residents, including painting, weaving and knitting. Residents are encouraged to eat in the dining room. One resident told the inspector that the food is very good, and 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 looked at by the inspector highlighted nutritional assessments, which linked to Menus, which were in place in the kitchen area of the home, these had been compiled through consultation with residents. Rooms have been individualised and were unique in design and décor to suit the needs of each resident. Residents are encouraged to maintain their rooms independently and are provided with equipment and facilities to support them to do their own washing. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 different levels of 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 and strong links with community health professionals are maintained as part of this process. A random inspection of resident’s medication records provided good evidence of appropriate record keeping and signatures to confirm medication administration is undertaken in the right way. All staff administrating medication have received appropriate training, and the Deputy Manager demonstrated a good understanding of the medical support needs of each resident. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents and family carers are encouraged by the care team 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 home has not needed to invoke the adult protection procedures during the last year. The Deputy 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 and was able to describe the process that he would follow should a concern linked to the protection of adults be raised. Residents meetings are organised by the Manager and Deputy Manager, and held regularly to ensure that residents are consulted about their needs and wishes. Family carers are also encouraged to maintain contact with residents and the staff team so that wherever appropriate, through the consent of individual residents they are able to take part in the care plan review process, and in the monitoring of quality and performance of practice within the home. During the inspection one resident told the Inspector that “The staff here are very nice, they listen to me and my key worker supports me at all times”. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. The home is well maintained, clean and provides a supportive environment for all residents. EVIDENCE: The home is a detached property located on one of the main roads into Mablethorpe Town Centre and is in easy walking distance from local amenities including shops, pubs and the seaside. Two residents told the Inspector that they found it easy to access the facilities they need and were supported to use transport to get to wider locations. 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. Residents told the inspector they were extremely happy with their environment and expressed satisfaction of their own rooms. The Inspector observed residents rooms to be highly personalised and well maintained. One resident showed the Inspector her room and said, “ I am really happy here, I get all the support I need to have my room and keep it the way I want it”. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 15 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. 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 Deputy 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. Staff files looked at confirms that staff receive appropriate checks prior to commencing in post and that induction is undertaken. Most of the staff team are trained to either NVQ level two or three, and through a discussion with the deputy Manager on the day of inspection the inspector was able to view a training plan, which 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 and Deputy Manager. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 16 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 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 ninetythree, is undertaking an NVQ4 Managers award, 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 their own skills, and services within the home. The Manager and Deputy Manager have a range of systems in place which demonstrate that they take their roles and responsibilities seriously, and regard the meeting of residents social and physical needs as central to the culture within the home. Waverley DS0000002471.V268367.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 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 4 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X X X 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 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Waverley Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 4 X X X X 3 X DS0000002471.V268367.R01.S.doc Version 5.0 Page 18 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.V268367.R01.S.doc Version 5.0 Page 19 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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