Inspection on 12/05/06 for Wendleberrie House

This inspection was carried out on 12th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wendleberrie House 04/11/05

Wendleberrie House 18/05/05

Wendleberrie House 27/09/04

Wendleberrie House 15/04/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Wendleberrie House 3 The Avenue Wellingborough Northants NN8 4ET Lead Inspector Mrs Sarah Smart Unannounced Inspection 12th May 2006 08:50 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wendleberrie House DS0000012950.V293107.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 Older People and 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. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wendleberrie House Address 3 The Avenue Wellingborough Northants NN8 4ET 01933 442160 01933 440999 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) jwfeatherstone@hotmail.com Mr John Winston Featherstone Mrs Lynette Featherstone Mrs Lynette Featherstone Care Home 8 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (8) Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2005 Brief Description of the Service: Wendleberrie House is small family run home providing personal care for up to 8 service users, within the categories of Old Age, Mental Health and Dementia over the age of 65 years. The home provides respite and long term care residential care, it does not provide nursing care. The home is privately owned with the Registered Persons having their own personal accommodation on the top floor of the premises; the Home has two single rooms and three shared rooms for the use of service users. Some of these bedrooms and the communal spaces, being the lounge and dining room, are on the ground floor. There is one kitchen from which meals for both the family and the service users are prepared. The home is located within walking distance of the main town centre and has its own large gardens, which are laid mainly to lawn. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 08.50 and 12.30. Preparation for the inspection included, review of the previous inspection report, requirements and recommendations, and service history, and took approximately 3 hours. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, medication, sample of policy review, staff rota, staff files, quality assurance, staff supervision, accident records, complaints records, sample tour of the premises, previous requirements made, and staff and service user interviews. service users were case tracked, and were selected at random during the tour of the premises, and included a service users who had been at the home for sometime, and a new service user. Two staff members, plus one of the owners, were spoken with at length, and several others briefly, whilst four service users were spoken to in detail. The fees currently charged by the home are £348.00 per week. What the service does well: Service users contract contain all of the required information. Service users stated that they had made a positive decision to share a bedroom. The service users appeared relaxed and comfortable in the home, and able to make independent decisions about their daily lives. Care plans were written to an acceptable standard, which lead to full and informative risk assessments. Generally medication was managed appropriately. Service users stated that their privacy and dignity is protected. Although one service user stated that she feels bored, records indicated that activities are offered to this service user, and the documentation showed that adequate activities are offered. Some service users go out into the local community alone, and the home demonstrated that the risks associated with this are appropriately assessed. Service users said that the food is nice, and they can choose what they eat. Breakfast time was observed to be relaxed. Staff knowledge of the homes policies and procedures in relation to complaints and abuse was satisfactory. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 6 Whilst the environment of the home will benefit from the proposed refurbishment and extension, the premises was satisfactory at the time of the inspection. Service users stated that they are happy with their rooms, and the home was clean and tidy. The staff rota was satisfactory, and the home is adequately staffed. Staff training was up to date. Documentation relating to recruitment was satisfactory. Quality monitoring is carried out on a regular basis. Records demonstrated that staff supervision is carried out regularly. Records relating to fire, accidents and Portable Appliance Tests were satisfactory. 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. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users are adequately informed by the information available to them. EVIDENCE: A sample of service users files were viewed. One contained a contract of residency, whilst the other did not. The contract seen gave the service users all of the required information. Two male service users who had recently moved into the home advised that they had chosen to share a bedroom, as they knew each other prior to moving into the home. They appeared comfortable in the home, and able to make choices about their daily lives. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 9 The home does not provide intermediate care. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users health and personal care needs are met, but documentation is not available in all instances to support this. EVIDENCE: Care plans were written to an acceptable standard, and were reviewed. From the written care plans, risk assessments were identified and written. Risk Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 11 assessments were written to a high standard, and covered all areas. The previous requirement in relation to care plans was met. One service users file contained a healthcare assessment in relation to nutrition, which had not been scored fully. A second had one relating to pressure sores which was satisfactory. Such assessments should be introduced for all service users. The requirement made previously in relation to healthcare assessments remains un met. A sample of medication was viewed. One service users medication was not being given as prescribed, and there were a few gaps in the records. One tube of eye drops with a short open shelf life did not have a date of opening recorded. Otherwise recording and storage of medication was satisfactory. Service users spoken to stated that their privacy and dignity is maintained, and shared rooms were noted to have privacy screens in them. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Service users social needs are met so that service users retain meaningful and fulfilled lives. EVIDENCE: A board containing forthcoming activities was displayed in the lounge of the home. An activities file demonstrated the activities available, however one service users spoken to stated that she feels bored. Documentary evidence Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 13 showed that this particular service user often declines to take part in the activities. Two other service users spoken to go out of the home unaccompanied, and risk assessments were written to support this activity. The home monitor the whereabouts of one of these service users on an ad hoc basis. Both of these service users were pleased to retain their independence in this way. Staff spoke to the inspector about the types of activities held. Service users stated that their relatives are welcomed into the home at any time. Service users added that the food is nice, and they can choose what they would like to eat. One of the owners stated that they often try new dishes, within the wishes of the service users. Service users were observed eating breakfast in a relaxed atmosphere. Records were held in service users files as to who ate what each mealtime. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Complaints and protection of service users are appropriately handled, meaning that service users are safe in the home. EVIDENCE: The home have not received any complaints since the last inspection. The complaints policy contained satisfactory information. Service users spoken to stated that they see the owner/manager regularly. The home have a copy of the Northamptonshire interagency abuse policy, which the staff appeared to be familiar with. Staff spoken to demonstrated awareness of, and correct handling, should they receive a complaint or an allegation of abuse. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. The areas of the home viewed were fit for purpose, and meet the service users needs. EVIDENCE: A sample tour of the premises was undertaken. Some areas of the home are used both for the home, and by the owners, who have separate Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 16 accommodation upstairs. All areas of the home area accessible to the service users, and the home stands in large gardens, which the service users said they like to use. Records in the kitchen were satisfactory, and food was covered appropriately, although not labelled in the fridge. Shared service users bedrooms had privacy screens in place. All areas of the home were clean and tidy at the time of the inspection. Service uses advised the inspector that they are happy with their rooms, and like to share with another service user. The owner stated that plans are being submitted to upgrade and extend the property. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome group is good. This judgment has been made using available evidence, including a visit to the service. Staffing levels and recruitment were adequate to meet the needs of the service users. EVIDENCE: The staff rota was viewed. This demonstrated that there are no staff members working excessive hours. The home is staffed by two staff on each day shift, and one waking night staff supported by a sleeping member of staff. Service users stated that their needs are met, and that call bells are answered promptly. Staff advised that should extra staff be required, then this is supplied. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 18 Staff training was maintained to a high standard, and certificates for a wide range of training and study days were seen in each staff members file. All statutory training was up to date. A sample of staff files were viewed. These were maintained to a very high standard. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome group is adequate. This judgment has been made using available evidence, including a visit to the service. Some areas of management should be more robust to ensure that the correct service users are admitted to the home, and protected from financial abuse. EVIDENCE: Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 20 The home is appropriately managed. It became evident during the case tracking that a service user has recently been admitted to the home outside of the homes categories of registration. An application for variation should be submitted as a matter of urgency. Quality monitoring is undertaken. Questionnaires are sent to service users and staff, but also the owner advised that people are asked verbally for feedback. A sample of service users money was viewed. Whilst some service users money was recorded appropriately, others were not, and legible and auditable records were not held. Staff supervision was recorded adequately, meeting a previous requirement. Fire records held were satisfactory, as were Portable Appliance Tests. Accident records were adequately recorded, meeting a previous requirement. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 2 36 X 37 X 38 3 Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP8 OP35 Good Practice Recommendations Healthcare assessments should be in place, accurate and regularly reviewed. Service users money should be recorded in a legible and auditable way. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Wendleberrie House DS0000012950.V293107.R01.S.doc Version 5.1 Page 24 - 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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