Inspection on 06/09/05 for WCS - Dewar Close

This inspection was carried out on 6th September 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

WCS - Dewar Close 26/09/06

WCS - Dewar Close 28/02/06

WCS - Dewar Close 06/12/04

WCS - Dewar Close 11/06/04

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE WCS - Dewar Close 5 Beech Drive Bilton Rugby Warwickshire CV22 7LT Lead Inspector Louise Thompson Unannounced Inspection 6th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service WCS - Dewar Close Address 5 Beech Drive Bilton Rugby Warwickshire CV22 7LT 01788 811724 01788 816253 admin@wcsdewar.fa.co.uk 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) Warwickshire Care Services Limited Ms Jacqueline Howe Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2004 Brief Description of the Service: Dewar Close provides long-term residential care for 37 frail older people and day care for up to a further eight older people. Accommodation for service users is on three floors, which are all accessible via a slow moving lift. There are two or three lounge/dining areas on each floor. In addition to three staircases there is a shaft lift. An assisted bath and shower plus two toilets are available on each floor. 22 of the bedrooms have private en-suite toilets and wash hand basins. The home provides a range of equipment designed to promote independence and to enhance the health, safety and welfare of service users. There is a loop system fitted in the main lounge on each floor as well as raised toilet seats, grab rails and specialist equipment to assist with moving and handling. Library books are also available in large print. A significant number of service users’ private rooms can accommodate wheelchair users. The main kitchen, laundry, offices and day care facility for eight older people are located on the ground floor of the accommodation. A small kitchenette is provided for the use of service users, staff and visitors in the main lounge/dining room on each floor. The gardens have been landscaped and provide accessible seating areas for service users. There are seats just outside of the main entrance to the home. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. This was the first visit for this inspection year. Staff co operated fully with the inspection. The newly appointed manager was on induction at the time of this visit and was present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents, staff and general practitioners visiting on the day of the inspection. 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. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 There is a clear pre-admission assessment, which assures that residents’ care needs can be met prior to moving into the home. EVIDENCE: The files of two recently admitted residents observed contained evidence of suitable pre admission assessment by the homes manager. Care management assessments and care plans were available for those who are supported by local authority funding. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Care plans require further development to provide the staff with the necessary information to meet individual residents needs. Health needs of residents are met with evidence of liaison with health and social care professionals on a regular basis. The arrangement for the storage of some medications is unsatisfactory and has the potential to lead to discrepancies. Personal support is offered in such a way as to maintain residents’ privacy and dignity. EVIDENCE: The home has recently introduced a comprehensive new care planning and quality management system. The records of three residents were observed during this inspection. Two of the files viewed had little/no evidence of a written care plan. Discussions with the manager and staff suggested that care needs were being addressed, even though there was a lack of clear plans and guidance. This approach is dependent upon staff memory and good verbal communication systems. Staff said that a current vacancy for a lead carer was partially responsible for the lack of suitable care plans. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 9 Good risk assessments were observed with ongoing monthly reviews of these, which enable staff to monitor changing dependency levels. Care documentation requires a quality questionnaire to be completed monthly along with a review of care plans. Staff had not recorded any changes to care in this section. The current format does not require care plans to be dated it was not possible to identify and track fully these monthly reviews. Staff said that they were learning how to use the new documentation and were finding it easier the more they did. Care files viewed showed involvement of members of the multidisciplinary team in assessing and meeting residents’ care needs. Two GP’s were visiting at the time of this inspection. The arrangement for the management and administration of medications were observed. The following issues were identified and discussed: • • • Not all prn medications specified the reason for administration. A small number of omissions in the administration records. Medicines for return and current stock were stored together in a drawer of a filing cabinet. Throughout the inspection it was observed that staff knock on residents’ doors, offer choices and ensure that all personal care and consultations are conducted in private, this assists in maintaining the residents privacy and dignity. Residents said that staff were very good to them and that their care needs were well met. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed as part of this inspection. EVIDENCE: WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 Systems for the management of complaints are satisfactory residents can be confident that their concerns are listened to, taken seriously and acted up on. EVIDENCE: Residents told the inspector that if they had any concerns about any aspect of the service they would discuss these with the manager or her deputy. The complaints/comments procedure is located on a notice board in reception. The inspector observed the complaints records, which included details of investigations and any action taken as a result. The CSCI has not received any complaints since the last inspection visit. A recent comment entered into the register prior to the inspection recorded. “ My mother loves being able to talk to someone, she feels much safer here and sleeps better. Thanks to all the caring staff.” WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed at this inspection visit. EVIDENCE: The home presents as comfortable and homely for residents. At the time of this visit the home was free from odours. A number of carpets particularly on the first floor required hovering. Residents and staff said that this was unusual and was due to annual leave of ancillary staff. Staff provided cover for this where possible. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27 and 29 Service users are being supported by a skilled and knowledgeable staff team who understand their needs and wishes. The recruitment policy and procedure must be more robust to ensure the protection of residents. EVIDENCE: The inspector observed the duty rotas for the period of a month. These demonstrated that although care staffing numbers were being maintained this was achieved by the manager and staff doing additional shifts to cover. Two staff said that there were difficulties in maintaining cover with lead carers due to a vacancy. Occasionally at weekends one lead carer would be responsible for medications over two or more floors. The home has vacancies for care and domestic staff and was recruiting to these positions at the time of this visit. The inspector examined the records of three staff members. Files of the two most recently appointed staff members contained evidence of suitable CRB checks, references and all other information as required by this standard. There was no completed CRB and only one reference on the third file. A management checklist on the front of each file evidenced that staff had been given copies of the General Social Care Council Code of Conduct. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 33 and 36 The quality management systems in this home are developing, with evidence that residents’ views are sought and acted upon. A suitable system for staff supervision is being implemented to ensure that staff has the support, skills, practices and knowledge to meet all of the residents needs. EVIDENCE: Since the last inspection a new manager has been appointed and was on her induction at the time of this visit. She is an experienced manager and is applying to the Commission for registration as manager at Dewar Close. A comprehensive quality management system linked to resident assessment and care planning has recently been implemented. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 15 A management matrix is completed monthly, which enables the homes manager and senior managers to monitor aspects of care and staffing throughout the home. This includes dependency levels and staffing, accident/incidents and complaints. Residents are asked one quality question each month and the responses are recorded. Throughout the year this will give an overall indication on residents views of the home. Resident meetings are held regularly with records of this seen at inspection. In addition to this there is a compliments/complaints book on each floor. Policies are produced corporately and are currently under review. Observation of records and discussion with the deputy manager demonstrate that some staff supervision is taking place. The manager said that this is being developed further with the new quality management system and the home was aiming to achieve a minimum of six supervisions each year for care staff. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 2 X x WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Timescale for action 31/12/05 2 OP9 13 3 OP29 19 Schedule 2 The registered manager must ensure that assessments and care plans are specific to each resident’s; health, personal and social care needs and are up to date. (Old timescale 31.01.05 not fully met) The registered manager shall 30/10/05 make arrangements for the safe handling, storage and recording of medication. The registered manager must 30/09/05 ensure that staff files contain evidence that two references and appropriate CRB /POVA checks have been completed for staff employed at the home. WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations The inspector recommends that the manager review arrangements for providing cover for annual leave and vacancies particularly for lead carers and ancillary staff. Ensuring that a suitable skill mix is maintained wherever possible. It is recommended that the staff in the home receive formal supervision at least six times a year and that all the areas listed in the standard are included in the process. 2 OP36 WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCS - Dewar Close DS0000004262.V249603.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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