Inspection on 08/06/06 for Wellpark

This inspection was carried out on 8th June 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wellpark 10/05/07

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 8th June 2006 08:50 Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 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.V289186.R01.S.doc Version 5.1 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.V289186.R01.S.doc Version 5.1 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 Mrs Rosalind Wills Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 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 £834 to £2289.39 per week. Additional charges are made to service users for transport, toiletries and personal items. Reports from the Commission are available to relatives and service users upon request. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9.5 hours with the manager present throughout. All but one service user has difficulties with verbal communication and were therefore unable to contribute fully to the inspection process. Almost most of the inspection was spent with service users and observations were made throughout the day. Five staff, including two agency staff were consulted and their views on the home discussed. All permanent staff at the home and regular agency staff were sent surveys prior to the inspection. Fourteen in total were returned. Comment cards were sent to GPs, care managers and visiting professionals. Four were returned. All relatives who gave permission were contacted either by telephone or by survey. Four contributed to the inspection and gave their views of the home. Service user surveys were sent but none were returned. The manager said these were completed and sent in but the CSCI has no record of receiving them. The inspector looked at number of records during the course of the inspection and a tour of the property took place. What the service does well: Staff are supportive, caring, service user focused and respectful. Staff are provided with good information prior to a service user being admitted to the home. This ensures they are able to understand and help to meet service users’ needs. Plans of care are compiled for each service user, which provides staff with good guidelines and information to help support and meet service users’ needs safely. Health needs are highlighted in care plans and show they are monitored well. Staff work hard to provide social outings for service users that meets their needs and wishes. Some improvements are needed in this area. The relationships between staff, relatives and other professionals are good. This ensures service users are supported to maintain family contacts. Professionals and relatives are involved and kept informed of any changes to services or individual care. The food provided is varied, balanced and healthy, which helps service users maintain a healthy and nutritious life style. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 6 Relatives, staff and service users are provided with a complaint’s policy. Relatives felt confident they would be listened to and any concerns dealt with appropriately. A service user said staff listened to her and always tried to resolve any concerns she raised. Service users are protected from potential abuse with well-trained staff who demonstrated a good understanding of abuse issues and what to do if they suspected any. Staff training has provided staff with a better understanding of health & safety issues and the skills needed to help meet service users’ needs safely. Half of staff have either achieved or are in the process of obtaining a qualification in NVQ level 2 or above. This means service users are cared for by suitably qualified staff. Wellpark is a homely environment that is clean, decorated and furnished adequately; and on the whole, meets the needs of service users. The home is being run more effectively with a supportive manager and deputy, who have received better systems and support from the new company now running the home. Audits of the service have been completed ensuring the home is run in the best interests of service users. What has improved since the last inspection? There have been significant improvements at the home since the new providers have taken over the running of the home. The manager has received more support and a deputy manager has been appointed. There have been staff changes, which has had a positive impact on the service. Policies and procedures have been updated and put into practice, service users’ care plans have been reviewed and made more useable and accessible to staff. The attitudes of staff appear more positive and more service user focused. Staff, including agency staff demonstrated an improved knowledge of care plans, guidelines and risks for all service users. Bathrooms and bedroom doors are no longer kept locked, making them accessible to service users. Training for staff has improved. For example most staff have received training in all health & safety topics, adult protection and training that helps them to understand service users’ needs. There is an ongoing programme of training events in the coming months. This will ensure service users’ needs are met effectively with staff who are skilled and competent. Fire safety practices and assessments of risk have improved ensuring service users’ and staffs’ safety and welfare is protected. However, a small improvement is needed in relation to fire alarm system checks. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 7 On the whole, recruitment practices have improved thus ensuring service uses are protected from potential abuse. However, improvements are still needed on terms of reference checks. Medication practices have improved since the home was investigated through a complaint received by the Commission in relation to medication. The CSCI pharmacy inspector assessed the medication practices in the home, during this inspection. On the whole, he was satisfied, but made one requirement in relation to medication taken out of the home. What they could do better: Care plans should be further developed to ensure service users’ wishes and goals are recorded and daily records should reflect whether they have been met or not. This will help staff to have the information to review care plans effectively and ensure progress has been made. Decisions that might infringe upon service users’ freedom of movement and choice should be discussed and agreed within a multi-disciplinary setting, such as a Good Practice Committee. For example, the locking of the kitchen door, front door and garden gates. Staff should consider evening activities for residents in and out of the home. A greater variety of activities, leisure pursuits and therapeutic activities should be explored for service users. Some medication practices must improve in relation to medication taken out of the home when service users go on visits home or trips out. The manager should ensure that broken furniture (dining chairs) are replaced to enable service users and staff to have the choice of eating together. Any unpleasant odours within the home should be identified and eliminated. Recruitment practices must be improved further. For example ensuring two suitable references are obtained before staff begin working at the home. This will further protect service users from potential abuse. Fire alarm checks must be carried out regularly to ensure service users’ and staffs’ safety and welfare are fully protected. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 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. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 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.V289186.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1& 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Sufficent information is gathered prior to admission to ensure the home is able to meet service users’ needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide relatives, service users and professionals with information about the home. Each service user has a copy of the Statement of Purpose in their care plan. The manager agreed that it would benefit the service users more if they had a Service User Guide and was in a format suitable to each person’s communication needs, for example an audiotape. Detailed assessments on service users’ needs were carried out prior to admission. There was also good information from previous placements. This enabled the home to establish whether they were able to meet their needs. One service user talked about visiting the home before admission. Relatives said they were involved in the admission process and had received good information about the home. Some carers said they were provided with good information about service users’ needs prior to admission. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with good information to meet service users’ needs safely. Improvements are needed to ensure service users’ wishes and goals are recorded. EVIDENCE: Plans of care are completed for each service user. These have been updated recently and are now more accessible to staff. Previously care plans were locked in the upstairs office, not all staff had keys to the office. Therefore care plans were not being used effectively. The plans have now been moved to the home’s downstairs’ office. The care plans set out individual needs and any associated risks. This enables staff to have the information they require to help meet service users’ needs safely. However, service users’ wishes and goals have not been recorded in every care plan, therefore care plans are not being used on a daily basis as a working tool and daily records do not necessarily reflect service users’ progress or achievements. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 12 A service user confirmed their involvement in the drawing up of their care plan. Relatives and care managers also confirmed that they attended regular care plan reviews. At previous inspections care staff had a limited knowledge of care plans. During this inspection all staff demonstrated a good awareness of care plans guidelines and action they needed to take to reduce any risk to service users. An agency staff said the risk assessments were particularly useful when working with individual service users or when planning activities. Due to the complex needs, risks and behaviours of some service users the front door and kitchen door is kept locked, in addition a small gate before the front door and a side gate are also locked. The manager has arranged a meeting with multi-professionals (A Good Practice Committee) to discuss these restrictive practices and hopes agree a long-term plan to move away from locked doors within the home. Relatives and care managers were consulted about the locked doors and have written agreements to these practices. During previous inspections, bedrooms and most bathroom doors were kept locked. This was due to one service user entering bedrooms and using en-suite bathrooms for baths and using toiletries. All bedroom doors and bathrooms are now kept unlocked. However, staff said the service user is still using other service users’ bedrooms, bathrooms and toiletries inappropriately. Some staff said this could cause aggressive outbursts when asking him to leave the rooms. They also said the bedrooms that are “targeted” are never used by the service users during the day. The home is in the process of fitting locked bathroom cabinets in en-suite rooms in the hope this will discourage him from wanting to access the rooms. If this is unsuccessful it will be discussed at a multi-disciplinary meeting (A Good Practice Committee) to find alternative solutions. There is a requirement to move away from locked doors and find suitable alternatives, by October 2006. Any hazards within the home or with individuals are assessed and any action needed to minimise risks to service users is recorded. This ensures staff have the information they require to keep service users safe. Staff demonstrated a good awareness of individual risks. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community, however some improvements are needed to the amount of activities and leisure pursuits that are arranged for service users. Service users benefit from a varied diet. EVIDENCE: One service user talked about what she did during the week, she had an activity chart in her bedroom that set out each day’s events. The service user confirmed her involvement and agreement in drawing up the chart. Examples on the activity chart listed, art & craft sessions, shopping, café, walks and household chores. The service user said she was happy knowing what she is doing each day. The staff team have worked hard to improve activities for service users. Service users’ daily records confirmed that service users go out daily at Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 14 different points in the day. However, improvements are needed in evening activities and more organised and therapeutic activities for all service users. For example, two service users’ assessments stated that they enjoyed swimming but this has not been arranged. The home has introduced a large notice board with places of interest to visit. The manager said this had been completed with service users. However a staff member was frustrated at being unable to arrange these types of trips. For example she said she wanted to arrange a trip to the zoo for the service user she was key worker for, but has been unsuccessful so far. The staff member said because of transport and staffing, trips like this never seem to happen. She said it said due to the complex needs of each service user most require two staff while out. This limits the length of time service users can go out individually to enable all service users to take a turn at going out. During the inspection service users were in and out throughout the day, for walks, trips out in the car and one service user attended an art and craft session. During the inspection staff were doing some papier-mâché work with one service user, some were completing puzzles and one was dancing to a video that had been put on. Throughout the inspection staff were seen to be kind, patient and respectful. The staff spoken to had a caring attitude and understood service users’ rights. Relatives spoke highly of the care their relatives receive. One talked about how supportive the staff are in supporting and enabling contact and visits. The food provided in the home is healthy and varied. A service user confirmed she liked the food and said she was offered an alternative if she did not like what was being prepared. Menus are displayed in the kitchen; they confirmed a healthy and varied diet is provided. Staff had a good awareness of service users’ favourite foods and dislikes. The inspector shared lunch with service users, which was pasta salad or other salads if preferred. One service user did not seem keen and asked for a pot noodle, which staff bought and prepared for him. An agency staff felt that the menu could be better arranged to ensure fresh vegetables were provided every day. The manager agreed to re-arrange the menu to achieve this. Fresh fruit bowls are put in the lounge each day and service users were seen to help themselves. The kitchen remains inaccessible to service users without staff support. Although some service users were seen using the kitchen with staff, none were able to go in alone. This is partly due to the complex needs of service users and could potentially be dangerous to them and others. However, it was agreed that if the kitchen were laid out better, it would be less dangerous and may eventually become safe for service users to have more access. The manager has arranged for some work to be carried out in the kitchen to enable this to happen. She has also arranged a meeting with multi-professionals (A Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 15 Good Practice Committee) to discuss this restrictive practice and to agree a long-term plan to move away from locked doors within the home. (See recommendation number two) Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are well met. Service users’ dignity and privacy is respected. Medication within the home is well managed although there are some concerns over the supply of leave medication. EVIDENCE: Personal care and support is provided by staff. One service user said that staff respected their preferences. For example, at night she liked to have drinks, a flask of tea and a jug of juice is prepared and kept in her room for her use during the night. Care plans describe preferences, likes and dislikes. Each service user living at Wellpark has a complex and diverse need, which staff try to understand and cater for. Staff demonstrated a good knowledge of service users’ preferences and gave examples of how they preferred to receive their care, including personal care. Care plans provided information about service users’ health care needs. Good records were kept of appointments to Dentists, Doctors, Chiropody and so on. The home has introduced new health appointment sheets, covering all aspects Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 17 of health. This will able staff to monitor health needs more effectively. Relatives said that the home was “excellent” in meeting health care needs and, on the whole, involved them in appointments where appropriate. Medication systems in the home were inspected by the CSCI’s Pharmacy inspector. The Medication Administration Record was well maintained and had few gaps evident. The actual dose administered for medicines prescribed with a variable dose was not always recorded. For episodes of social leave it was recorded that medication had been supplied. However this record whilst recording the quantity of “When Required” medication supplied did not record the quantity supplied of regular medication. The supplies of leave medication have an insert sheet describing the medication and dose however the individual containers are not labelled. This means that it was not always possible to be certain that service users had been given the correct medication for periods of social leave. All staff administering medication has been assessed by the manager as competent to carry out this task and have all received appropriate training with additional training planned as needed. The lists of current medication in some service users care plans did not reflect the medication actually being administered. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are fully protected from abuse. EVIDENCE: The home has a complaint’s procedure in formats that help service users with communication difficulties understand. Each service user has a copy of the complaint’s procedure in their bedroom. One service user was able to express when she was unhappy and said staff listened to her. This was observed throughout the inspection. Relatives said they felt confident in raising concerns to the staff and manager. They consistently said that any concerns they have raised have always been dealt with effectively. Since the last inspection one formal complaint was received by the CSCI. This related to the quality of food within the home and medication practices. A random inspection took place and did not uphold the issue relating to the quality of food but did uphold the medication practices. Since then the home has improved their practices. The CSCI also received a concern from an agency staff about the general care and practices within the home. It was agreed these issues would be looked at during this inspection. The result of which is reflected throughout this report. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 19 All service users’ monies are managed by their relatives, who have Power of Attorney. Spending money is given to the home or service users. Good records are kept and receipts are sent to relatives at the end of each month. All of the current staff team have received training on Adult Protection. All staff spoken with demonstrated an excellent understanding of abuse and knew what to do should they suspect any. One service user said she felt “very safe” living at the home. Relatives said they were confident in the team’s ability to keep their relatives safe. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homely envirnoment meets the needs of current service users. Improvements are needed in relation to service users’ freedom and choice around the home, some furniture and some odours. EVIDENCE: Wellpark is a large detached property in Exeter. There are good-sized gardens and car parking on site. The property is decorated and furnished to a good standard making the house feel homely and bright. Each service user has their own bedroom that are decorated and furnished according to individual interests, needs and preferences. Each of the bedrooms are bright, attractive and comfortable. Decorations, pictures and possessions displayed in the rooms reflected the interests and tastes of each service user. The manager toured the building with the inspector and agreed there were slightly unpleasant odours in two bedrooms. The lounge and dining rooms appeared comfortable, stylish and homely. However, there are not enough dining chairs for staff and service users to eat around the same tables. Staff said often some service users choose to sit in Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 21 the garden and one chooses to sit in the lounge. This was observed during the inspection. The manager agreed that more dining chairs were required before the winter months. The laundry facilities had no hand washing or drying facilities. This was put right during the inspection. The front door to the house has a fence and gate that is only accessible with a swipe card lock as is the front door. Although relatives and families feel this is safer for service users due to the busy road outside, the manager had agreed to discuss this further within a multi-disciplinary setting, such as a Good Practice Committee. This work has not been completed yet. During the last inspection, bedroom and bathroom doors were also kept locked. This is no longer the case. (See section 6 – 10) The kitchen door remains locked although there is work to improve this. (See section 6 – 10) Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are not fully protected by robust recruitment procedures. Service users are supported by enough caring and trained staff to meet their needs. EVIDENCE: The home provides a good ratio of staff to meet service users’ needs. On the day of the inspection they were three regular staff and two agency staff on duty. The Commission sent surveys to regular and agency staff prior to the inspection to seek their views of the home, a mixed response was received. Many of the agency staff said the home was “controlling”, the management was “poor” and the food was “of poor quality”. Regular staff also gave mixed responses some said the home was improving, other said the training and support was “inadequate”. Since these surveys were received a lot of changes have taken place. For example, some staff no longer work at the home, the providers have changed, only regular agency staff work there, a lot of training has taken place for staff and new deputy manager has been employed. On the day of the inspection the atmosphere was relaxed and friendly. Staff were observed being caring, patient and respectful towards service users. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 23 Service users were provided with choices throughout the day. For example, in food and what and where they wanted to go. Agency and regular staff spoken with said the atmosphere in the home had changed in recent months with a change of staff, positive team meetings, more training and support from management. They said the home was more “relaxed and homely”. Service users appeared relaxed and happy and one said she was happy with the staff team and confirmed that they were kind and respectful. One relative said the staff were “excellent and very supportive”, another relative provided very positive feedback in a questionnaire sent by the Commission. During the last key inspection a requirement was made in relation to poor recruitment practices. Some staff had started working at the home before appropriate checks had been completed, therefore putting service users at risk. Three relatively new staffs’ files were inspected on this occasion. All had police and Pova (CRB) checks, all had proof of identity checked before starting work in the home, however only one reference could be found on file for these three staff. The manager felt these had been obtained but had not been sent by head office. At the last inspection a requirement was made to provide better training for staff that would help and support them to meet service users’ needs safely. The providers and management have worked hard to achieve this with all staff having received training in the Protection of Vulnerable Adults. The majority of staff have also received training in Conflict Resolution, mandatory health & safety training and Safe Holding techniques. A rolling programme of training is to continue to ensure service users are protected with appropriately trained staff. The manager said Total Communication training is booked for most staff in coming months. All staff spoken with including agency staff were able to demonstrate a good understanding of abuse awareness and what they should do if they suspect any. The home has appropriate policies and procedures in relation to abuse awareness and has the local Alertor’s guide for staff to follow in the event of reporting abuse. All staff were aware of these policies. Service users are therefore better protected from potential abuse. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of service users. Systems to review, develop and improve the home have been developed. Service users’ safety and welfare are protected. Improvements are needed in some safety checks. EVIDENCE: The manager and newly appointed deputy manager have worked hard to raise the standards within the home. Team meetings, the reconstruction of service users’ care plans, better support systems for staff, improved food and a general change of attitude and ethos in the home has improved the lives for service users. Most staff felt they were now provided with clear leadership and direction and felt the home had “turned a corner” and would continue to improve. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 25 The manager completes audits of the service through, for example care plan reviews, staff supervision and meetings, environmental and health & safety checks, audits of medication, accidents, complaints and finances. Service users and relatives are consulted about their views on the home and services. This quality audit ensures the home is being run efficiently and effectively and in the best interests of service users. Once a full audit has been completed the manager fills in a form with all of the findings, which is then scored and a percentage is obtained against each standard audited. The company requires action plans if an optimum score is not reached. The CSCI obtains information prior to inspections. The information includes conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. In this instance policies and procedures were in place. During the last two inspections requirements were made relating to fire safety checks, including the testing of the fire alarm systems, fire training and fire risk assessments. Requirements and recommendations were also made following a visit to the home from the Fire Department. All requirements and recommendations from the Fire Department have been met. However, on the day of the inspection, the fire logbook showed that alarm systems had not been checked for 3 weeks. The person responsible for these checks had been on holiday and had forgotten to delegate the job to another staff. The manager thought this had been completed through a recent fire evacuation drill. During the inspection the person responsible for these checks filled in the home’s diary for each week to ensure the staff on duty complete the tests. This will ensure that all staff take responsibility of ensuring the alarm system is working correctly and therefore protecting service users’ safety and welfare. Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 26 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 X 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 2 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 3 X X 2 X Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Timescale for action The registered person shall make 08/08/06 arrangements for the recording and safe administration of medicines in the care home. This refers to the need to ensure that the actual dose administered is recorded for all medication prescribed with a variable dose. The registered person shall make arrangements for the recording of all medicines in the care home. This refers to the need to ensure that a clear record is made of all medication leaving the home for social leave and of any medication returned to the home after this period of leave. The registered person shall not 30/07/06 employ a person to work in the care home unless – He is satisfied on reasonable grounds to the authenticity of the references referred to in paragraph 5 of schedule 5 in respect of that person. (This refers to have to written references before some starts working in the home) DS0000062704.V289186.R01.S.doc Version 5.1 Page 28 Requirement 2. YA34 19 Wellpark 3 YA42 23 The registered person shall make 15/07/06 adequate arrangements for the reviewing fire precautions; and testing fire equipment, at suitable intervals. 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. 2. Refer to Standard YA6 YA7 Good Practice Recommendations Services users’ wishes and goals should be recorded consistently and daily records should reflect if goals are being met. Practices of freedom of choice or movement should be discussed and agreed with families and other professionals with records kept. For example a Good Practice Committee. (This refers to the locked kitchen door, front gate and front door) Staff should consider evening activities for residents in and out of the home. A great variety of activities, leisure pursuits and therapeutic activities should be explored for residents. The manager should ensure broken furniture (dining chairs) are replaced and that the home is free from unpleasant odours. 3. YA12 4. YA24 Wellpark DS0000062704.V289186.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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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