Inspection on 10/05/07 for Wellpark

This inspection was carried out on 10th May 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wellpark 08/06/06

Wellpark 29/11/05

Wellpark 13/04/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Wellpark Wellpark Alphington Road St Thomas Exeter Devon EX2 8AU Lead Inspector Belinda Heginworth Unannounced Inspection 10th May 2007 08:50 Wellpark DS0000062704.V331286.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 Wellpark DS0000062704.V331286.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. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellpark Address 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) Wellpark Alphington Road St Thomas Exeter Devon EX2 8AU 01392 217387 Networking Care Partnerships (SW) Ltd ** Post Vacant *** Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2006 Brief Description of the Service: Wellpark provides support and personal care for up to eight people with a learning disability and complex needs. The home is a detached house situated on a busy road in Exeter near Exeter Quay. The house is on three levels. There is a large lounge, dining room, laundry room, kitchen and en-suite bedroom on the ground floor. The upper levels house the remaining bedrooms, an additional communal room, an office and bathrooms. There is a large secure garden to the rear of the property. The fees for the home range from £234 to £866.35 per week. No additional charges are made to people other than toiletries and personal items. Reports from the Commission are displayed in the entrance hall and office. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during a weekday. The inspection was carried out over a period of 5 hours and 20 minutes, starting at 08.50am. The manager was present throughout the inspection. Some of the people living at the home have limited communication skills and behaviours that challenge the service. Most people were therefore unable to fully contribute verbally to the inspection process. Time was spent with all people and observations were made throughout the inspection. One person was consulted fully and their views on the home discussed. We also spoke with four members of staff, one agency staff and the manager. Prior to the inspection the manager completed a questionnaire, which provides information about the people living at the home, staffing, fees and confirms that necessary policies and procedures are in place. This information helps the commission to prepare for the inspection, send out surveys to appropriate people and helps the commission form a judgement on how well the service is run. Before the inspection took place, surveys were sent to the people living at the home. They were also sent to staff, relatives and comment cards were sent to professionals who are connected to the home. One staff survey was returned. One comment card from health care professional and two surveys from the people living at the home were returned. During the inspection we “case tracked” three people living at the home. This means we spoke with them, made observations, spoke with staff and read records, starting from the admissions process through to the present. Medication practices were looked at and a tour of the home took place. We inspected other records. These included, the fire safety information, staff training records, menus, quality assurance records and recruitment files. What the service does well: The acting manager and organisation who run the home are working hard to improve this service and make it safer. The people living in the home have very complex needs, which often means high levels of aggression are displayed. The staff team are constantly trying to ensure people are not at risk but still providing a balance of meeting peoples’ needs. High levels of staffing means people are able to use local facilities for social needs. On the day of the inspection one person was looking forward to going to a café at Exeter Quay. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 6 Although there are still areas to improve on, communication between staff and with management is good. Staff said the manager is very supportive and helps to guide them in good practices. On the whole, medication practices are safe with further improvements needed. People’s health needs are assessed and monitored appropriately. The systems in place to review the quality of the service is good with regular audits being completed and actions to improve the service. Some further detail is necessary to ensure the work is completed. (See “what they could do better”) What has improved since the last inspection? What they could do better: Care plans need to be more useful to staff, currently they are not organised well making it difficult to find information quickly. Peoples’ records provide a lot of information but do not include short or long term goals. They are not used as a working document with people’s wishes and goals being included. Many areas that pose a risk are highlighted, assessed and good action is recorded on how to reduce the risk. However, some of the risk assessments do not relate to the care plans. For example, one risk assessment was about reducing aggression towards other people living in the home. It stated the risk to others, the level of the risk and what should be done to reduce it. It made no mention of how to avoid the risk by following the guidelines in the care plan. Although the staff team work hard to ensure people lead full and active lives, this has been hampered for some time because of one person’s needs. For example, the transport is used daily for this person which means other people Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 7 who cannot use public transport can only go out locally. The organisation is aware of this and is trying hard to resolve the situation. The people living in the home have limited communication and the home needs to seek advice from a speech and language therapist. This will help the home produce suitable methods of communication for each person living in the home. It will also provide people with more opportunity to express their feelings, wishes and choices in their lifestyles. Many meetings take place to review the progress of the people living in the home and assess the quality of the service as a whole. Although these minutes are useful, the action needed to improve things have no time scale or person responsible for making sure it is completed. There is a risk of the improvements not taking place within an acceptable time frame. The manager intends to move away from practices that restrict people’s movement around the home but still ensuring they remain safe. For example, the kitchen door is kept locked unless people using it are under close supervision. However, there is no clear long or short term plan on how they will achieve this. There needs to be an accurate record of medicines that leave the home to ensure there is an account of medicines left in the home. People go home with relatives but sometimes do not give the medication prescribed. No action has been taken, or advice sought, to ensure this is a safe practice. Medicines are kept in blister packs, divided into the days of the week, over a period of 4 weeks. Many medicines had been taken out of the wrong day. Although there is a clear label explaining the error, the manager should carry out an assessment of staffs’ competencies to ensure they remain safe to administer medicines, therefore protecting peoples’ health & welfare. On the day of the inspection the home had a very strong and unpleasant smell of damp and mould. The carpets had been cleaned the day before but staff said the smell had been there for a while. The manager hopes to replace the carpets soon, which may resolve the issue. This needs to be completed as a matter of urgency because it is very unpleasant to live in. The communal areas in the house are limited. This can make it difficult for people to get away from each other. It can and has lead to aggressive incidents. The manager needs to consider making better use of some spare rooms in the house. These could be used as activity/ quiet rooms. This might reduce the incidents of aggression and give people a choice of where they want to spend their time. The home should try to find a way of including people’s views on how the home is run, they should also include outside stake holders views, to ensure the home is being run in the best interest of the people living there. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 9 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 Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensures people can make an informed choice of where they would like to live. It also provides staff with the information they require to ensure peoples’ needs can be met. EVIDENCE: The majority of the people living in the home have lived there since it opened. Detailed assessments on peoples’ needs were carried out prior to admission. There is also good information from previous placements. This enabled the home to establish whether they were able to meet their needs. One person was able to talk about visiting the home before moving in. Relatives were also fully involved in the admission process. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with information to help meet peoples’ needs but their wishes and goals are not included in this information. This means there is a risk of inconsistency in how care is delivered and no system to ensure the care is what the person needs or wants. EVIDENCE: Good information is in peoples’ files but they do not formulate a plan of care taking into account people’s wishes and goals. They are not being used on a daily basis as a working tool and daily records do not necessarily reflect peoples’ progress or achievements. The organisation of the records does not make it easy to find information quickly. This means staff may miss reading about risks and people could be cared for inconstantly. Recent reviews have taken place in “key worker meetings” but did not involve the person living in the home or their representative. Although minutes were taken of these meetings there was no recorded actions, time scales and someone with responsibility to ensuring the work was completed. For example, one of the Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 12 minutes recorded in March 2007 said “need to purchase a jelly mat, bowl and spoon”, “implement into personal care cutting or file one nail after showering”, “assessment re continence” and “mobility for shoes and wheelchair”. There was no time scale in which to achieve these things and no one was recorded as being responsible. Daily records, the home’s communication book and the person’s records gave no indication if any of this work had been completed. The manager explained that the organisation has standardised formats for peoples’ records. These are divided into sections making easier to find information. The manager hopes to complete these soon. Staff spoken with had a good knowledge of peoples’ needs and risks, however most of this knowledge came from communicating with other staff. The majority said they did not use the care plans as a working tool and rarely read them. Some staff used them when reviewing care but only those they were key worker for. Reviews take place with care managers and people living in the home, if appropriate, or their representative, however plans of care are not drawn up as a result of these reviews. One person living in the home said they were involved in reviews and staff supported them in making decisions. Due to the complex needs, risks and behaviours of some of the people living at the home, the front door and kitchen door is kept locked. These restrictive practices were discussed with other professionals (A Good Practice Committee). It was agreed that a long-term plan was needed to eventually move away from using these locks. Relatives and care managers were consulted about the locked doors and have written agreements to these practices. However, due to some recent complex behaviour of one person, the home has struggled to find a way to come up with short and long term solutions. The manager agreed that having a long-term plan of action recorded would ensure the locked doors don’t continue to be a normal practice and get forgotten about. Any hazards within the home or with individuals are assessed and any action needed to reduce risks to people is recorded. This ensures staff have the information they require to keep people safe. Staff demonstrated a good awareness of individual risks. However, some risk assessments did not relate to care plans, for example, one was to prevent other people being hurt through aggressive outbursts from one person. The assessment highlighted the risk, recorded control measures already in place and additional control measures needed. There was no reference to information in the care plan that may help prevent the outburst in the first place. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are treated respectfully and supported to make choices about their lifestyles and maintaining relationships with families and friends. People are provided with choices of well-balanced meals which they sometimes help prepare. EVIDENCE: One person talked about their “time table” they helped to chose. This included going to an art and craft class, music workshops, walks, cafes, shopping and lunches out. In the hallway of the home a time table of activities for everyone is displayed. It shows a fairly wide range of activities are offered and take into account people’s preferences. However, these have not been followed recently due to the complex needs of one person. The manager hopes this will be resolved soon. On the day of the inspection two people were enjoying Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 14 completing puzzles in the dining room, one was watching TV in the lounge and other were still getting up. The limited communication of the people living at the home gives staff a challenge in ensuring people are provided with choices in their lifestyles. Many decisions are made through observations, staff’s knowledge , staff and care plan review meetings. The manager intends to introduce better communication systems that help people express their wishes and choices. Seeking advice from a speech and language therapist might help the home to produce suitable communication systems for each person living in the home. Menus show a well-balanced diet is provided. One person living in the home said they are offered some choices and are given an alternative if they do not like what is offered. People are supported to use the kitchen under close supervision. One person said they were able to help prepare some foods and drinks. The remainder of the time the kitchen is kept locked. During the inspection, one person was given a “pot noodle” for lunch, this was the person’s choice and staff respected this. A menu is displayed in the dining room, using photographs of the food being offered that day. Currently, the photographs were limited, the manager said they are obtaining more as they go along. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ dignity and privacy is fully respected and people benefit from their health needs being closely monitored. Medication practices are on the whole good, but some practices do not fully protect peoples’ health and welfare. EVIDENCE: One person said the staff were “very kind” and said they helped and supported them in how they liked to receive their personal care. Staff were observed throughout the inspection being respectful in their manner and approach to everyone living in the home. Each person living at Wellpark has a complex and diverse need, which staff try to understand and cater for. Staff demonstrated a good knowledge of peoples’ preferences and gave examples of how they preferred to receive their care and support, including personal care. People’s records provided good information about health needs and monitoring. The home liaises with appropriate professionals when necessary. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 16 The home has recently had a lot of difficulties managing the complex needs of someone living in the home. This has resulted in injuries to staff; and some other people living in the home being put at risk of being hurt or living in fear. The home has worked hard to arrange an admission to a health unit for assessment and treatment and hopes this will be resolved within a week. The staff are to be commended for their commitment and support they have shown during this very difficult period. The home uses a monitored dosage system for medication. All staff who administer medicines receive training. Medication practices are on the whole well managed but some blister packs had medication taken from the wrong day. Although a label explained the error, the manager should investigate the cause of such errors to ensure they are not repeated. When people go home medication blister packs and administration sheets are sent home with relatives. On many occasions, relatives had signed on the back of the sheet saying “not given”. The home should discuss this with the GP to ensure not giving prescribed medication is safe. This should then be discussed with the relatives to ensure the health needs of the person are not being compromised. All medication leaving the home should be checked and signed out and back on their return to ensure the correct medication is sent out and returned. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 17 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. 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. People living at the home are assured they are listened to and complaints are dealt with appropriately. More appropriate complaint formats for people with limited communication needs might help them to express when they are unhappy. There are good systems in place to ensure people are protected from abuse. EVIDENCE: The Commission and the home have received no complaints about the home or care since the last inspection. The home has a written complaint’s policy and one on audiotape. One person living at the home said, if they were unhappy, they would speak to staff or friends at the art and craft class they attend. Other people living in the home are unable to verbally say when they are unhappy, apart from through shouting or perhaps crying. Staff have a good knowledge and awareness of when people are not happy and work hard to resolve the problem. The home has a lot of incidents of aggression, many of these may be caused by frustrations in communication. A speech and language therapist may be able to help the home come up with suitable formats for people to use to express their feelings and therefore avoid aggressive outburst. The home has good systems in place to protect people from potential abuse. This includes good training, good recruitment and financial practices. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 18 Some staff have received training on adult protection and are also made aware as part of their induction. The manager has booked more training on this in the next few months. All staff spoken with had an excellent understanding of abuse awareness and what to do if they suspected any. Service users’ finances are managed through their relatives with the home receiving money from them when necessary. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The size and layout of the home does not fully meet peoples’ needs and the poor odours are unpleasant and offensive. EVIDENCE: One person living in the home was proud of their bedroom, they had a key and said they had recently had their room decorated in colours of their choice. All bedrooms are decorated and furnished according to individuals’ needs, choice and taste. The home has a large lounge and dining room which people can access freely. The kitchen is only accessible under staff supervision. This is due to the complex needs of the people living in the home and would currently be unsafe. Due to these complex needs there is a high level of staffing. Currently there are six people living in the home and usually six staff, often seven. Although staff try to get people out of the house as much as possible, the house can be crowded and noisy. This can sometimes lead to incidents of aggression. A room Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 20 at the top of the house was meant to be turned into a sensory / quiet room. This has not happened. There is already a “staff meeting” room on this floor but no extra communal rooms have been made available to the people living in the home. The home is registered for eight people but there are no plans at the moment to admit any more people, therefore some bedrooms could be turned into sensory rooms/ quiet rooms/ games rooms. This may enable staff to provide more individual care and support away from other people living in the home; and perhaps prevent incidents of aggression. On the day of the inspection the home had an extremely unpleasant odour of mould and damp. The manager said this had been caused by the carpets being cleaned the day before. Staff said the smell has been there for sometime and the carpet cleaning was to try and solve the problem. The manager hopes to replace the carpets. This must be resolved quickly as it cannot be pleasant to live in. The remainder of the home was clean and tidy, however many areas are looking “tatty” and are in need of re-decoration. Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by enough caring, experienced and well recruited staff. People will benefit further when staff have received up dates on training that related to their specific needs. EVIDENCE: Staff were observed throughout the inspection being kind, patient and respectful towards the people living in the home. One person said “they liked the staff” and said they were “kind”. Some of the staff team have a received a good range of training that helps keep people safe and helps them understand and meet peoples’ needs. The manager has completed an audit to highlight further training necessary. Health & Safety, Protection of Vulnerable Adults, Total Communication and Medication training has been booked over the next few months. Staff spoken with demonstrated a good awareness and understanding of people’s needs. The organisation has produced a detailed induction booklet for new staff to work through. The manager said the standards are in line with the Learning Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 22 Disability Award Framework (LDAF). These are standards expected within learning disabilities services. The knowledge gained from this induction will help staff towards achieving National Vocational Qualifications (NVQ). Three staff have achieved this qualification and 2 are in the process. The manager intends to enrol the majority of the staff team to complete this award. The recruitment practices were found to be good ensuring the correct checks, including police checks (CRBs) are completed before someone starts working at the home. This ensures people are protected from potential abuse. Wellpark DS0000062704.V331286.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. 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. People benefit from a well managed and safe home that will improve further when people’s views and wishes are part of the process. EVIDENCE: The current manager has been working at the home in an “acting” capacity and is not registered with the commission yet. The manager has many years of experience of being a registered manager at another care home. She is currently completing a degree in sociology, the registered manager’s award and NVQ level 4 in care. Staff spoke very positively of the changes and the support the manager has implemented. One person living in the home said the manager “was nice”. Some staff were not so positive about the deputy manager, saying “things Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 24 don’t get done” and there is a “click” in the home of old and new staff. The manager is hoping with some team building, more meetings and supervision and support this will improve. The manager completes a quality audit for the organisation each month. This assesses areas of health & safety, environment, people living in the home, administrative work, staffing, training, recruitment, complaints and many more. Once completed, depending on the answers, produces a score. This scores provides the home with a percentage, if below a certain percent, the home has to produce an action plan for improvement. Discussions took place about including time scales and people responsible to help ensure improvements take place. Surveys have been sent to relatives to seek their views on how the home is run. The manager has also arranged a relatives’ meeting. A system to seek the views of the people living in the home has to be found. The manager also intends to seek the views of outside stakeholders. These quality assurance systems will ensure the home is being run in the best interests of the people living in the home. The fire logbook was found to be up to date and accurate. Fire risk assessments are due to be updated 22/05/07, staff training was completed, therefore protecting peoples’ safety and welfare. The home has recently had an environmental risk assessment audit completed by an outside company. The home is currently working through the recommendations made. A questionnaire was completed by the manager prior to the site visit. This provides information about the people living in the home, staff, and fees and indicates whether necessary policies are in place. The information helps the commission prepare for the inspection and send surveys to appropriate people. It is also used to help the commission form a judgement as to whether the home is being run appropriately and safely. In this instance this information, the site visit and responses to surveys indicates the home is being run well. Wellpark DS0000062704.V331286.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X 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 3 3 2 X 3 X 2 X X 3 X Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 26 Yes 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. 1. Standard YA20 Regulation 13 Requirement There needs to be a clear record of all medication leaving the home for social leave and of any medication returned to the home after this period of leave. (Previous time scale 08/08/07) The manager must ensure staff remain competent to administer medicines and therefore prevent errors occurring. The manager should seek professional advice when prescribed medication is not administered to ensure the practice is safe. 2 3. 4. YA24 YA24 YA30 23, 2 (D) 23, 1(a & G) 16, 2, (K) The home must be reasonably decorated. There must be enough communal space to meet the social needs of people. The home must be free from offensive odours. 30/08/07 30/08/07 25/06/07 Timescale for action 20/06/07 Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 27 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 YA6 Good Practice Recommendations Peoples’ care plans should be more organised to make them easier to follow, they should include peoples’ wishes and goals, they should be recorded consistently and daily records should reflect if goals are being met. Practices of that restrict people’s freedom of choice or movement should be reviewed regularly and a short/long term plan should be compiled to works towards these practices, ensuring people remain safe. (This refers to the locked kitchen door) The home should seek advice from appropriate professionals to help find suitable communication methods that will help people be able to express their feelings, wishes and choices. Risk assessments should refer to care plans where appropriate to ensure some actions to prevent risk include guidelines in care plans. The home should produce a communication system that will help support people to express when they are unhappy. The quality assurance systems that check that the home is being run in the best interests of people, should include the views of the people living in home and outside stake holders. Time scales for improvements should also be included and named people responsible for ensuring the work is completed. 2. YA7 3. 4. 5. YA9 YA22 YA39 Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wellpark DS0000062704.V331286.R01.S.doc Version 5.2 Page 29 - 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. 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