Inspection on 18/05/05 for Wendleberrie House

This inspection was carried out on 18th May 2005.

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

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

Other inspections for this house

Wendleberrie House 12/05/06

Wendleberrie House 04/11/05

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 HOMES FOR OLDER PEOPLE Wendleberrie House 3 The Avenue Wendleberrie Northants NN8 4ET Lead Inspector Sarah Smart Unannounced 18 May 2005 09.30 th 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wendleberrie House Address 3 The Avenue Wendleberrie Northants NN8 4ET 01933 422160 01933 440999 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr John Featherstone Mrs Lynette Featherstone Care Home 8 Category(ies) of OP Old Age (8) registration, with number DE(E) Dementia - Over 65 (8) of places MD(E) Mental Disorder - Over 65 (8) Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th September 2004 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 C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 9.30am and 13.30pm. The pre-inspection questionnaire had not been completed and will be sent out and included in the next inspection. 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, accident records, complaints records, the statement of purpose, tour of the premises, fire records, previous requirements made, and staff and service user interviews. Two service users were case tracked. One staff member, plus the manager, was interviewed at length, whilst two service users were spoken to in detail. What the service does well: What has improved since the last inspection? The statement of purpose has been improved upon, as have care plans and the management of medication. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 6 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 C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 A small amount of additional information in the statement of purpose and the service users contracts will adequately inform service users. The information given is sufficient for the service users to be able to make choices. Service users needs are met. EVIDENCE: The statement of purpose had been reviewed since the last inspection, and mainly contained satisfactory information, although it was still lacking the owner and managers address. The statement of purpose did not state that the night staff sleep, and are available to be called, rather than being on waking duty. The service user contracts of residency clearly stated the fees payable, although this did not include the charges for extras. The contract also did not state the room to be occupied, or the insurance arrangements. The service user case tracked had been at the home for many years. The assessments had been reviewed, and contained satisfactory information. Documentation, and discussion with service users and staff indicated that the service users current needs are met. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 9 Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The home are failing to assess, identify and therefore address the service users changing needs in relation to healthcare. Service users personal care is currently met, but recording is not adequate. EVIDENCE: Care plans viewed were generally written to an acceptable standard. In particular one service users care plan for social interaction and stimulation was written to a high standard. One care plan was slightly out of date, in that a service user had recently decided to wear pads, however this was not stated in her care plan. One service users file contained a pressure sore risk score, which was totalled incorrectly, however the other did not. Neither file contained a nutritional score, and one service user who required it, did not have a continence assessment carried out. In one instance assessments had not been reviewed since 2003. Medication was generally managed in a satisfactory manner, and the previous requirement had been met. However, a drug error was identified by the inspector, which the owner manager had not picked up, and had therefore not notified the Commission for Social Care Inspection. The medication policy did Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 11 not state that the Commission for Social Care Inspection must be notified of drug errors. Two service users spoken to stated that their privacy is maintained, and shared service user bedrooms were noted to have privacy screens in place. The confidentiality policy gave limited information, and did not cover giving information over the telephone, or staff conversations outside the home. The death policy did not state that the Commission for Social Care Inspection must be notified. Service users files did not demonstrate that service users wishes in the event of their death were sought. The owner/manager stated that she would expect the service users relatives to make the necessary decisions and arrangements. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service users dietary, and social, needs are met. EVIDENCE: One service user spoken to stated that she goes out regularly independently. Her notes indicated that risk assessments pertaining to this were in place, however the service user described a potentially dangerous situation in which she had found herself during one of her trips out alone. This was brought to the attention of the owner/manager, who was previously unaware of this. The owner/manager agreed that her risk assessment must be reviewed, and practices changed. This service user regularly goes to church, and is able to invite visitors into her room in the home. A second service user stated that there are limited activities available in the home, and she would like to, but doesn’t go to church. Her file demonstrated a care plan in relation to social activities and stimulation. This was regularly reviewed, and clearly stated that the service user is regularly offered activities, but declines to partake. Staff spoken to stated that they make every attempt to encourage and enable the service user to join in. The day prior to the inspection a reminiscence therapist has visited the home. The inspector observed that service users are encouraged to be as independent as possible. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 13 A planned menu was displayed on the notice board, and indicated the choices given. Appropriate records were held in relation to food in the kitchen. Service users stated that they enjoy the food. Lunch on the day of the inspection appeared balanced and appetising. One service users special diet is catered for. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Service users are protected from abuse within the home. Complaint handling is satisfactory. EVIDENCE: The owner/manager stated that the home have not received any complaints since the last inspection. The complaints policy was acceptable, and staff spoken to demonstrated a good knowledge of the procedure. Service users spoken to stated that they had been enabled to vote in the recent elections. The abuse policy was satisfactory, and made reference to the Inter-agency policy for the Protection of Vulnerable Adults. This document was also available in the home. The staff member spoken to stated that she would take action were she to witness abuse in the home, however she did not state that this action would be immediate. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The facilities provided enable the needs of the service users to be met. EVIDENCE: All areas of the home were accessible to the service users. The previous requirement in relation to a maintenance plan has not been met. Service users stated that they like to sit in the garden during the summer months. The home has a lounge and dining room. Neither of these rooms have a call bell, and service users stated that they would have to shout if they needed assistance. Staff pointed out that the communal rooms are in very close proximity to each other, and the kitchen, meaning staff would hear if service users required their attention. The owner/manager stated that if required by the service users, a call bell would be supplied in the lounge. Service users bedrooms have wash hand basins in them, and in addition to this the home has a selection of toilets and bathrooms which are accessible to them. The home has a bath hoist, a general hoist and a stair lift. Staff spoken to stated that all the equipment is in working order. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 16 The home has several shared bedrooms, which all have privacy screens in place. Service users rooms viewed were adequately furnished, and personalised by the individual. One service users room was rather cluttered, but the service user stated that this is her choice. Staff have recognised that this may cause a hazard in relation to trips and falls, or fire, and are taking sensitive steps to reach a mutually agreeable level of storage within the service users room. The owner/manager stated that a risk assessment had been carried out in relation to the unrestricted first floor windows, meeting the previously made requirement, although she was unable to provide the inspector with this document. The home was clean and tidy. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The staffing levels are appropriate to meet the current needs of the service users. EVIDENCE: The staff rota indicated that two staff members are on duty during the morning shift, and two during the afternoon and evening. The night shift is covered by the owner/manager and her husband who sleep in the home. Service users stated that the staff meet their needs and have time to carry out their duties. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Poor documentation means that service users are not safely protected, despite acceptable risk assessments. EVIDENCE: The fire records had not been completed for four weeks. One service user advised the inspector that she had had two recent falls, however these were not recorded in the accident book. The home have a preprinted type accident book, however this was empty, and the home are continuing to use a blank book, meaning that vital information is not recorded. Areas of risk were identified for each service user, and risk assessments were written to an acceptable standard. All radiators were covered with low surface temperature covers. The owner/manager stated that the front door key is held on a hook, and not on the carers person. This had been the subject of a previous requirement which remains unmet. The hook is some distance from the front door, and if Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 19 the fire was to occur between the door, and the storage place, service users and staffs exit from the home would be compromised. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x x x 2 Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 21 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. 2. Standard 8 8 Regulation 12(1) 12(1) Requirement Timescale for action by 30.6.05 3. 38 12(1) 4. 19 23 Healthcare assessments must be in place, accurate and regualrly reviewed. By 30.6.05 Where the District Nurse provides training to named staff members to conduct invasive healthcare procedures on his/her behalf, full documentation of this training must be available for Inspection, including permission from the DIstrict Nurse for staff to carry out the procedure. A copy of this documentation must be forwarded to the Commission. This was a previous requirement made in 9.04, which remains unmet. First floor windows should be risk By 30.6.05 assessed to establish any need for window restrictors in view of the category of service users for which the home is registered. A copy of the risk assessment must be sent to the commission. This was a previous requirement made in 9.04, which remains unmet. A programme of routine By 30.8.05 maintenance and renewal of the fabric and decoration of the premises must be produced. This Version 1.30 Page 22 Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc 5. 29 19 6. 36 18 7. 38 23(4) 8. 9. 10. 11. 9 12 38 38 13(2) 12(1)(a) 23(4) 17(1) was a previous requirement made in 9.04, which remains unmet. This previous requirement was not checked at this inspection. There must be evidence of prospective staffs medical fitness to undertake their duties, and to this end doctor’s references must be followed up where necessary. This previous requirement was not checked at this inspection. There must be evidence of staff receiving regular formal supervision no less than 6 times a year. Staff must each carry the key to the front door on their person when on duty. This was a previous requirement made in 9.04, which remains unmet. Drug errors must be notified to the commission. The drug policy must reflect this. The risk assessment relating to one service user going out alone must be reviewed. Records must be maintained of weekly fire equipemnt checks. All accidents must be recorded accurately and must include all of the required information. By October 30th 2004 By October 30th 2004 By 30.6.05 By 15.7.05 By 30.6.05 By 30.6.05 by 30.6.05 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 1 2 Good Practice Recommendations Shortfalls on the homes Statement of Purpose must be resolved. This was a previous requirement made in 9.04, which remains unmet. Contracts should contain all information as detailed under Standard 2. This was a previous recomendation made in 9.04, which is unmet. C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 23 Wendleberrie House 3. 4. 11 10 Service users wishes in the event of their death should be ascertained, and recorded. The death policy should state that the death should be notified to the commission. The confidentiality policy should advise staff in relation to telephone calls and conversations between staff outside the work environment. Wendleberrie House C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 C51 C08 S12950 Wendleberrie House V228329 180505 Stage 4.doc Version 1.30 Page 25 - 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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