Inspection on 29/09/06 for Wellesley House Residential Care Home

This inspection was carried out on 29th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wellesley House Residential Care... 26/03/06

Wellesley House Residential Care... 13/04/05

Wellesley House Residential Care... 17/09/04

Wellesley House Residential Care... 27/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Wellesley House Residential Care Home 10 Wellington Road Bury Lancs BL9 9BG Lead Inspector Sue Evans Unannounced Inspection 29th September 2006 09:50 Wellesley House Residential Care Home DS0000008427.V297334.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 Wellesley House Residential Care Home DS0000008427.V297334.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. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellesley House Residential Care Home Address 10 Wellington Road Bury Lancs BL9 9BG 0161 761 6932 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) Mrs Linda Bell Mrs Janet Kinsella Mrs Linda Bell Mrs Janet Kinsella Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is registered for a maximum of 4 service-users to include: Up to 4 service-users in the category LD (Learning Disabilities). The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 26th March 2006 Date of last inspection Brief Description of the Service: Wellesley House is home to four people who have learning disabilities and need support to lead independent lives. The house is a large terraced property half a mile from the centre of Bury. There is a park opposite the house, and main bus routes and various amenities are within easy reach. There are two lounges, a kitchen and separate dining room on the ground floor. Upstairs, there are four single bedrooms with en-suite facilities, and a separate bathroom. Outside, there is a small front garden, and an enclosed yard at the rear, with decking where people can sit out in nice weather. Standard weekly fees are currently between £988 and £994. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home. Seven hours were spent in the home, watching what went on, talking to the 4 residents, two staff members, and the co-manager, Janet Kinsella, looking round the home, and examining some key records. Several weeks before the visit, questionnaires were sent to the home to be given out to residents and regular visitors. All 4 residents returned completed questionnaires. Written comments were also received from 3 relatives. What the service does well: Wellesley House is in a residential area and the house blends in with neighbouring houses. It has a pleasant, homely atmosphere. Bedrooms are single, and en-suite, giving residents space and privacy. Written and verbal comments from residents indicated that they were happy living there. Comments from residents included, “I like it here, the staff are nice”. The staff members who were spoken with were knowledgeable about the needs and wishes of the residents, and are aware of how their needs are to be supported. Staff talk to residents about their goals, and give them the support they need to achieve them. Residents, and the relatives who sent in written comments, all felt satisfied with the standard of care in the home. Residents are helped to become involved in community activities such as employment, college courses and leisure pursuits, helping them to lead lives that are meaningful and fulfilling. The numbers of staff on duty are arranged to accommodate this. Regular residents meetings are held. Residents’ comments indicated that they felt that staff listened to them and acted upon their wishes. Residents said that they had choice about their daily routines, for example what time they got up, and how they spent their time. They confirmed that their privacy was respected, for example staff members always knocked on their bedroom doors. Residents confirmed that staff members treated them well and spoke courteously to them. This was seen during the visit. Staff members understand that they have a responsibility to protect residents by reporting any suspicions of abuse. Residents know what to do if they have any concerns or complaints, and they feel confident that they will be listened to. Staff members receive training and support to help them to do their jobs well. Managers work co-operatively with the CSCI, and any requirements or recommendations made during previous inspections have been acted upon. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 6 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. Wellesley House Residential Care Home DS0000008427.V297334.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 Wellesley House Residential Care Home DS0000008427.V297334.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): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Needs are assessed before anyone is admitted to the home, written information about what the home offers is provided, and trial visits are arranged, so that all concerned can decide whether the home will be suitable. EVIDENCE: The home had a Statement of Purpose, a Service Users’ Guide, and a brochure which described the service provided. The co-manager, Janet Kinsella, said that they were last updated in November 2005. She said that the Service Users’ Guide was produced in print with some pictures added. She said that, if necessary, it could be produced in other formats suited to individual needs. The home is advised to think about having it available in other formats, such as audio, so that any interested people who may have difficulty reading standard print, can find out about what the service offers. The current resident group had lived in the home for several years, and so there had been no recent admissions to the home. However, the written comments provided by the residents suggested that they had received enough information about the home before moving in. One commented, “I received a brochure and visited a lot before moving in. I had a house warming when I moved in”. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 9 Residents’ written and verbal comments indicated that they were happy living in the home. The co-manager said that any prospective new residents would be introduced to the home gradually, starting with a look round, perhaps staying for a meal and building up to overnight stays. She said that a Service Users’ Guide and brochure would be given to the person on the first visit so they could take it away with them. She said that the introductory visits would be done at the individual’s own pace. She said that the visits would be used to observe and get to know the person, so that a decision could be made about whether the home could meet their needs, and also whether the person would be compatible with the others living in the home. The personal files relating to 2 residents were looked at. Residents knew that the home had written information about them. The residents had lived in the home for several years, and file notes stated that the original care management assessments had been archived. However, there was evidence of reviews involving the placing authority. The co-manager said that care management assessments were always obtained before anyone came to live in the home. She said that the home would then carry out its own ongoing assessment whilst getting to know the new person. Care plans were developed from this initial information. The co-manager described the process when a new resident was recently admitted to a sister home. She said that a care management assessment had been obtained, and the home had gathered further information by completing a booklet “Listen to Me” with the resident. A copy of this booklet was shown to the inspector. Discussion took place with the co-manager and one of the staff members about whether the home would be equipped to meet the needs of residents from ethnic minority groups. They felt that the home would be able to do so after researching what was required, for example special dietary needs. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 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, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are included in reviewing their needs and goals. They are able to make choices and decisions about their lifestyles, and are assisted to be as independent as possible, whilst keeping any risks to their health and welfare to a minimum. EVIDENCE: The personal files of 2 of the residents were looked at. They contained a range of information, for example, care plans, risk assessments, review notes and other key information. Some of the documents were undated so it was unclear whether they were still current. The home is advised to remove outdated information to an overflow file, and to ensure that all documents are dated. Each care file contained an individual care plan, written in the first person, that included each resident’s strengths, needs, preferences and goals. Residents knew about their written records and knew that they could see them whenever they wanted. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 11 Personal plans were centred upon the 8 areas of community presence, independence, choice, individuality, status, respect and dignity, continuity, relationships, and culture. Progress in achieving goals was looked at regularly and recorded on ‘monthly update sheets’. More formal review meetings, to which relatives and social workers were invited, took place annually. Residents talked about their goals and confirmed that they attended meetings to review them. It was noted that a summary of each person’s goals was kept in the staff handover file, providing staff with a quick reference point. The staff members spoke knowledgeably about the needs of the residents, and the information that they gave was in line with the written information in the care notes. It was observed that the residents’ routines of daily living were flexible. For example residents got up at the times they chose, and they pursued their individual activities. They confirmed that they made their own decisions about their lifestyles. From discussions with staff and residents, observations, and written comments from residents, it was evident that residents had the opportunity to do things for themselves and be involved in the day to day running of the home. For example, 2 residents said that they went to Asda every week, with staff, to do the grocery shopping. The co-manager said that none of the residents had an independent advocate at present but, if required, they would use a Rochdale advocacy service. Residents’ managed their personal allowances to varying degrees depending upon need and risk. Residents said that they had regular residents’ meetings. During these meetings residents could discuss anything that was relevant to the group, for example new activities or menus. It was observed that all the residents could speak up for themselves, and they did not hesitate to approach the co-manager or staff if they had anything to say. Risk assessments had been completed, with risks balanced against the resident’s right to choice and independence. There were detailed behavioural management strategies covering a range of situations. Records showed that these were reviewed every 6 months. The residents and relatives who gave their views about the home said that they were satisfied with the support provided. One resident said “I like it here, staff are nice, I set goals and do reviews”. Discussions with one of the staff members showed that they understood what confidentiality meant. They said that the topic was included in staff induction training. Confidential records were safely stored in the office. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are assisted to take part in community activities that help them to live fulfilling, valued lifestyles. Care practices in the home respect residents’ rights, they are encouraged to eat healthily, and contact with family and friends encouraged. EVIDENCE: Discussions, observations and written records showed that residents took part in a range of activities. Staff support was provided for community activities as required. In the daytime, there were enough staff on duty to enable residents to engage in community activities. In the evenings, there was normally only 1 staff member on duty although on Thursday and Friday evenings 2 staff were on duty to enable residents to go out on their chosen activities. A staff member said that if residents wanted to take part in other outside activities in the evenings, for example theatre visits, extra staff would be rostered to work. Whilst such flexibility is very good, opportunities for spontaneous outside activities in the evening are limited. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 13 During the inspection visit, one resident went out doing voluntary work, and one went out to Bury centre with a staff member for shopping and lunch. All residents were looking forward to their regular Friday evening out for karaoke at a local pub. Residents described other regular community activities that they were involved in including college courses, meals out, walking, cycling, aqua aerobics, library visits, bowling, and the cinema. One resident went to a local Art group (START). Residents were supported with holidays if they wanted one. Two had been to Prestatyn with staff, one had been to Anglesey with staff, and another had been on a holiday organised by the local Gateway club. At home, people engaged in whatever they were interested in, for example watching TV or videos, listening to music, or doing jigsaws. Residents were encouraged to keep in contact with family and friends. Some regularly visited their families, or sometimes their families visited them. Residents’ involvement in the community gave them opportunities to meet new people. The relatives who sent in written comments said that they were made welcome in the home, and that they could see their relative in private. As already stated in this report, daily routines were flexible. For example, when not attending specific time-tabled activities, people could have a lie-in if they wanted. A staff member described how residents’ privacy was respected, for example by knocking on residents’ doors. This was confirmed by residents. Some residents took part in household tasks such as food shopping. Residents also helped to prepare meals and drinks, wash up, and keep their rooms tidy. It was observed during the inspection, that staff spoke respectfully to residents and there was a natural, friendly rapport. Menus suggested that a varied diet was provided. Healthy eating was encouraged, for example staff encouraged residents to eat fruit and vegetables. One resident who wanted to watch her weight was being helped and encouraged to follow a healthy diet. Residents were satisfied with the meals, and they said they had enough to eat. It was observed that drinks were available throughout the visit. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Personal and health care needs are promoted, and medication storage and procedures generally promote good health and safety. EVIDENCE: Residents mostly needed prompt and encouragement with personal care needs. Any assistance required was agreed in care plans. Discussions with staff suggested that they were discreet in supporting personal care needs. All rooms were en-suite, with toilet and shower, so residents could have a shower in the privacy of their own personal space. One staff member said that residents chose what to wear each day, and that staff would make suggestions if they chose something unsuitable, for example inappropriate clothing for the weather conditions. As already stated in this report, discussions with residents, showed that they had choices about their daily routines, for example what time they got up or went to bed. They said that they were happy with the way that staff members treated them. It was observed during the visit that there was a friendly rapport between residents and staff. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 15 Staff were aware of residents’ health needs, and discussions and records showed that they contacted other health professionals when necessary. Records were kept of individual health appointments, including GPs, Dentists and opticians. On the day of the inspection visit, a resident was accompanied by staff to a dental appointment, and another to the opticians. Records of weight monitoring were kept. Accident records were also kept. During discussions, staff demonstrated awareness of residents’ health needs, and they gave examples of how they encouraged and supported them to maintain good health, for example by taking appropriate exercise and following healthy eating plans. There were written guidelines covering medication, including guidelines for administering PRN medication. Medicines were kept locked away. Some stocks needed returning to the chemist. A monitored dosage system was being used which included pre-printed MAR (Medication Administration Records). The MAR sheets were generally appropriately completed. However, a situation had arisen whereby the pharmacist had been unable to deliver medicines on the designated day (Saturday). This meant that 2 residents did not have sufficient medicines for the weekend. The home had acted appropriately and obtained emergency supplies, and noted them in the receipts book. They had not cross referenced this with the MAR which made it appear, from checking the blister packs, that 2 days medication had not been given. However, the inspector was satisfied that the home had done its best to rectify the situation. Since the inspection visit, the managers have arranged an improved system. In future, medicines will be delivered to the home in advance so that, if delivery problems occur, this situation will not arise again. Records were kept of medicines received into the home, and returned. There was evidence to show that residents had given their consent to medicines being administered by staff. One resident’s self-administration risk assessment needed updating. It was dated August 2005 and was no longer relevant. In line with good practice, residents’ photographs were attached to the MAR to aid identification, and a list of staff members’ usual signatures was maintained. Staff members had received training in the safe handling of medicines. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents know how to complain and they feel they would be listened to. Protection policies and procedures, and staff understanding of their adult protection responsibilities, ensure that the service has the means to be able to respond appropriately to any suspicion or allegation of abuse. EVIDENCE: The service had a written complaints procedure. Details were included in the Service Users’ Guide. The home also had a ‘Complaints, Concerns and Compliments’ book. Residents’ verbal and written comments showed that they knew how to make a complaint (to a manager, a staff member, family, Social Services or CSCI). They felt that they would be listened to, and that something would be done. The relatives who sent back written comments said that they were aware of the complaints procedure. The home had a copy of the multi-agency adult protection procedures. Staff members were aware of their responsibility to report any suspicions of abuse. They said that they had done training in Adult Protection, both inhouse, and also as part of the LDAF (Learning Disability Award Framework) induction course, and NVQ 2. Evidence of the in-house training was seen. Staff members were also aware of the home’s policy on the acceptance of gifts. It was noted that the home ensured that staff had undergone POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) checks to ensure that they were suitable to work with vulnerable adults. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 17 Systems were in place to safeguard residents’ finances. One of the managers was appointee for 2 residents. The home had oversight of residents’ personal allowances, and residents were supported to manage their money as appropriate. Monies held in the home were checked daily to ensure the balances were correct. The home had a number of written policies covering, for example, bullying, equal opportunities and racial harassment. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides a homely, comfortable, clean and safe environment for those who live there. EVIDENCE: The home was situated in a residential area of Bury, not far from the town centre. It was close to bus routes, shops, and other local amenities. There was a park across the road. The house was a three storey terraced property. It was similar to other properties in the area, and therefore it did not stand out as a care home. Outside there was a small garden at the front, and an enclosed yard at the back, with decking where residents could sit out in nice weather. There was no passenger lift so access to upper floors was by stairs. Consequently, the home would not be able to meet the needs of a physically disabled person. All areas of the home were looked at except for one bedroom. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 19 The home had two comfortable lounges, one of which was a designated smoking area, a separate dining room, and a domestic style kitchen. The laundry room was in the basement, as was the office. Furnishings in the home were domestic in style. The home had a pet cat which the residents really liked, and which added to the homely atmosphere. There was a bathroom with sink and toilet on the 1st floor. Residents said that they were happy with their rooms. There were 4 single bedrooms - 3 on the 1st floor, and 1 on the 2nd floor. They had en-suite showers and toilets. Bedrooms were personalised with residents’ own items, and reflected their interests. One resident said that she had chosen her own colour scheme and curtains. Bedroom doors were fitted with locks for privacy and residents had their own keys. The manager said that there was an ongoing programme of re-decoration and refurbishment and that the planned maintenance programme was included in the home’s business plan. Whilst the environmental standards in the home are satisfactory at present, there will remain a need for ongoing redecoration and refurbishment in order to keep up standards. The necessary health and safety checks had been carried out (see final section of this report). The home looked clean and tidy. The home employs a domestic assistant, and residents also help with some household tasks. Liquid soap was provided for hand washing in the bathroom and kitchen. Kitchen towels were used for hand drying in the kitchen. There were no paper towels in the bathroom when the inspector looked, but staff and the manager said that the supply must have run out and not been replenished. The staff member said that there were stocks in the home and the matter would be dealt with. All 4 residents said in their written comments that the home was always fresh and clean. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 20 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, 33, 34, and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff members receive appropriate training and supervision to enable them to carry out their duties. In the main, residents are protected by safe recruitment practices. However, a requirement has arisen this time in respect of the references for one staff member. Despite this, on balance, the overall quality rating for this group of standards is still judged to be good. EVIDENCE: Discussions and examination of records showed that the staff team had a range of knowledge and experience. Observations showed that residents were quite comfortable in approaching staff members. Two staff files were looked at. contracts. One of the staff who given these documents. Staff staff had received a copy of Practice’. They contained copies of job descriptions and were spoken with confirmed that she had been files also contained signed confirmation that The General Social Care Council’s ‘Code of Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 21 During the visit it was observed that there was a friendly atmosphere between residents and staff. Residents said they were happy with the support they received from staff. Comments included, “I am happy with the staff.” Of the 6 support workers, 5 had achieved NVQ level 2 and another had a Diploma in Nursing. The home was therefore exceeding the target of having at least 50 of care staff trained to at least NVQ level 2. The gender mix of staff was good with both male and female support workers being part of the team. Staff rotas showed that there were normally 2 support workers on duty throughout the day, which meant that residents could be supported on activities outside the home. During Thursday and Friday evenings (4pm to 11pm) there were 2 support workers on duty to enable staff to support residents with Gateway Club (Thursdays) and karaoke (Fridays). On the other evenings there was only 1 support worker on duty, although a staff member said that extra staff would be brought in to cover any planned activities. For example 2 residents liked to go to the theatre, so extra staff would be on duty to facilitate this. The recruitment documents for 2 staff members were looked at. It was noted that the home had carried out CRB (Criminal Records Bureau) checks. Files also included application forms with employment histories, criminal convictions declarations, photographs, medical declarations and proof of identity. Staff members had also signed an agreement that they would inform the home if subsequently charged by the Police, and they were required to sign annually to confirm that they had no new convictions. Two written references were found on each staff members’ file, but in one case the references were dated later than the staff member’s starting date. The manager explained that the staff member had worked at one of the sister homes before moving to Wellesley House and other written references were held at the other home. She was asked to forward copies of the original references to the CSCI. Following the inspection visit, she sent a copy of one of the original references but said that the other had been mislaid. She said that she had contacted the employer in question and obtained a verbal reference in respect of that employment. Details were forwarded to the CSCI. During the inspection visit, discussion took place about the changes in the Care Homes Regulations, and the need for application forms to show the reasons for leaving previous jobs in care. One of the support workers who were spoken with said that new staff had induction training and shadowed more experienced staff for a time. Induction records were seen on staff files, and covered a number of areas including health and safety, confidentiality, and epilepsy. One of the managers had produced a new more in-depth induction pack for use with future new recruits. Training records also showed that staff had done LDAF (Learning Disability Award Framework) induction course. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 22 The support workers gave examples of some of the training that they had undertaken. This included NVQ, protection of vulnerable adults, medication, moving and handling, food hygiene, first aid, fire training, and LDAF (Learning Disability Award Framework). Copies of training certificates were held on personal files. One support worker said that a manager regularly did in house training in topics such as challenging behaviour and epilepsy. The manager said that ‘Learning Logs’ had just been introduced, whereby staff were encouraged to share learning. The support workers who were spoken with felt that the managers were approachable and that they listened. They said that an on call system was in place. One said that she had used the on call some time ago and the response was good. Staff said that they had annual appraisals and regular 1 to 1 supervision meetings with a manager. Records were seen. One support worker said that staff could request a 1 to 1 meeting anytime. The home had achieved ‘Investors In People’ status recognising the commitment to staff training and development. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgment has been made using available evidence including visits to this service. Residents benefit from a well run home where managers promote their health and welfare. EVIDENCE: Mrs Janet Kinsella and Mrs Linda Bell are the owners of 2 other homes as well as Wellesley House. Mrs Bell is registered as lead manager for Wellesley House, with Mrs Kinsella having a secondary role. These roles are reversed at one of the sister homes. The 3rd home in the group has another registered manager. Mrs Kinsella said that, although each home had a lead manager, they all worked across all 3 homes so that their combined skills and experience could be used in the most advantageous way. This was reflected in the sample rotas that were seen. All 3 managers have NVQ level 4 in care and the RMA (Registered Managers’ Award). Mrs Bell also has a post-graduate diploma in special needs. Mrs Kinsella was a college lecturer in special needs. Both have the LDAF level 4 in Challenging Behaviour. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 24 A staff member said that the home was well run. It was clear, from discussions and observations, that the managers encouraged an open atmosphere within the home. One staff member said that she received enough support and information to be able to do her job properly. Residents and staff said that they found managers to be approachable. During the inspection visit, residents were observed to be quite comfortable in approaching Mrs Kinsella. The managers work co-operatively with the CSCI and any requirements made during previous inspections have been acted upon. Communication within the home takes several forms including verbal handovers, written records, residents’ meetings, and staff meetings. The home had several methods for obtaining peoples’ views. Regular meetings took place, for staff and residents, where they could express their views. The home also produced a six-monthly newsletter which included details of feedback from residents that had been gathered throughout the preceding months. The views given were not anonymised. The manager said that the home did carry out bigger surveys that included anonymous questionnaires, and included the views of staff. She said that the most recently completed one was in April 2005, but the next one was almost completed. She said that it had included the views of a range of people including residents, relatives, staff, GPs, health professionals, day centre workers, and regular visitors to the home. The resulting improvement plan should show residents, and others, that that their views have been listened to and acted upon. A copy of the report should also be sent to the CSCI. Several safety records were checked. These included electrical installation, gas safety, portable electrical appliance tests, servicing of fire alarms, emergency lighting and fire fighting equipment, and weekly checking of fire alarms, emergency lighting, fire fighting equipment and means of escape. The last fire drill took place on 29/8/06. A test for Legionella was done in July. The home had a range of environmental risk assessments including a fire risk assessment. A valid Employers Liability Certificate was seen. Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 4 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 3 X 3 X X 3 X Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Timescale for action The medication self- 31/10/06 administration risk assessment for one service user needs updating. 2 written references must be 29/09/06 obtained before staff members commence employment and the references must be available for inspection by the CSCI. Requirement 2. YA34 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 YA1 Good Practice Recommendations The home needs to think about having key information, such as the Service Users’ Guide, available in formats other than print (for example audio tape) for those who cannot read standard print. The home is asked to remove outdated information from care files to an overflow file and to make sure that all documents are dated. DS0000008427.V297334.R01.S.doc Version 5.2 Page 27 2. YA6 Wellesley House Residential Care Home Wellesley House Residential Care Home DS0000008427.V297334.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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