Inspection on 04/11/05 for Wendleberrie House

This inspection was carried out on 4th November 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 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 HOMES FOR OLDER PEOPLE Wendleberrie House 3 The Avenue Wellingborough Northants NN8 4ET Lead Inspector Judith Roan Unannounced Inspection 4th November 2005 15:30 X10015.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.V263157.R01.S.doc Version 5.0 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. 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.V263157.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wendleberrie House Address 3 The Avenue Wellingborough Northants NN8 4ET 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) 01933 442160 01933 440999 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.V263157.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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.V263157.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 3 residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspection took place during the late afternoon, over a period of 3.5 hours and was carried out on an unannounced basis. A pre-inspection questionnaire has been received and will be reflected within this report. What the service does well: What has improved since the last inspection? What they could do better: Healthcare assessments and action plans remain poor and is again a requirement in this report. Service users are not asked of their wishes in the event of their death. Care plans need to contain personal goals and document progress through reviews. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 6 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.V263157.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 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 the following standard(s): 1,3,5,6, Information available and the opportunity to visit the home aid service users with the admission process. Service users admitted for intermediate care are not fully supported to take full advantage of services so that they may return home. EVIDENCE: Shortfalls in the homes Statement of Purpose have been addressed. The admissions process, which includes the option to visit the home prior to admission, enables service users to make a decision. A service user who had been admitted for a short period whilst they regained their health has remained at the home for considerably longer than expected. The inspector was concerned that the home had failed to make care plans that contained personal goals with regular reassessment on progress. This was discussed with the manger during the inspection and it was agreed that appropriate support would be sort. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 9 On the day of the inspection the care workers were caring for an elderly relative of the owner for a few hours. This was achievable within the homes registration as the number of service users being cared for was under 8. However if the home reaches its maximum number of service users the owner would need to apply for a variation in their registration. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 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 the following standard(s): 7,8,10,11 Practices at the home are still failing to address the health care needs of service users. Recording continues to be poor. Practices enable service users to have privacy and are respectful. EVIDENCE: Service users spoken with during the inspection confirmed that care workers were sensitive to their needs and respected their privacy. Care workers were seen to be positive within their communication with individuals. Where service users share a bedroom privacy screens are provided. Health care needs of individuals are not always met. In one service users file it is recommended that their legs be raised during the day to assist with the oedema. This was not feasible due to the location of the service users chair within the quiet area; as to do so would cause a tripping hazard for other service users and staff. In discussion with the Registered Manager it was agreed that a review of how the service users health care needs could be met would be undertaken. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 11 One service user had been admitted with depression and anxiety with a view to going home in the long term. Care plans did not demonstrate how they were to be supported to achieve this goal. The registered manager needs to review the plans with the service users and family and agree how present needs can be best met and discuss whether a referral is made to health care professionals to consider appropriate support. Care plans still fail to note the wishes of Service uses on the support needed at the time of their death and details of any arrangements. The Registered Manager was reluctant to discuss this with service users and their families. The inspector discussed with the Registered how this could be achieved in a sensitive and appropriate way. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 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 the following standard(s): 14,15 Service users are supported to make informed choices. EVIDENCE: Care plans demonstrate how service users are supported to make choices in relation to their daily routines. Service users are consulted about menus and activities within the home. The menus supplied as part of the pre inspection questionnaire show that service users have a balanced diet. Service user confirmed that the standard of meals was high. Activities normally take place in the quiet room. With limited communal space service users who do not wish to participate normally spend time in their bedrooms. Service users access the community for leisure options of their choice with support from care workers or family members. A service user who was going out independently has been risked assessed and the home now provides transport for this activity. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 16,18, Practices within the home ensure that service users are protected from abuse. Service users can be assured that their concerns and complaints will be acted upon. EVIDENCE: The home has a comprehensive complaints procedure that service users are fully aware of. A copy of this is available to all new service users and their families. The Registered Manager confirmed that there have been no complaints since the last inspection. In discussion with service users they are aware of how important it was to express concerns if they were unhappy with how they were being cared for. Staff had undertaken abuse awareness training as part of their induction and ongoing training. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19,20,21,23,24,25,26 The environment despite its need for routine maintenance remains clean and tidy. EVIDENCE: All areas of the home are accessible to service users by the provision of a stair lift if required and specialised equipment that is maintained in good working order. The home has two communal rooms available to service users. These rooms meet requirements but do limit the type of activities achievable. In discussion with the Registered Manager she informed the inspector that a review of the facilities is presently being undertaken. The additional care of the elderly relative within the home for a few hours on several days was also discussed. The homes communal areas would not provide adequate space for a further individual to be cared for and would infringe on the rights of existing service users. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 15 The home provides suitable bathing and toilet facilities to meet the needs of service users. Bedrooms were seen to be personalised and service users have the opportunity to use these for private time. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 16 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 Service users are protected by recruitment practices and training of staff at the home. EVIDENCE: Two care workers were on duty providing care for seven service users. This number increased on the arrival of an elderly relative for day care to eight service users. Service users care needs were not compromised as the ratio of staff was still within recommended levels. Service users agreed that staff had adequate time to meet their needs. A new member of staff has been recently appointed and in discussion with the inspector confirmed that she had been interviewed and that all relevant checks had been undertaken prior to her commencing duties at the home. Induction had been undertaken and they were attending college to improve their basic communication skill before starting National Vocational Qualification in care. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 17 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36 Service users interests are generally met by the homes practices. EVIDENCE: The home needs to continue development of an active quality assurance system that will demonstrate how the homes practices are being developed in the best interests of service users. The home only supports one service user with their finances. In discussion with the Registered Manager and view of records there is good evidence that service users are protected by the systems in place. The families of other service users are managed their finances. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 18 It was not possible to view supervision records for staff as the Registered Manager was using these as pert of her Registered Manager Award. The lack of records available at the home leads the inspector to make a further requirement at this inspection. Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 19 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 1 X X Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. 3. Standard OP7 OP8 OP36 Regulation 15 12(1) 18 Requirement Timescale for action 31/12/05 4. OP38 17(1) Care plans must include personal goals and reviewed on a regular basis Healthcare assessments must be 31/12/05 in place, accurate and regularly reviewed. This requirement has been made 31/12/05 at the last two inspections. There must be evidence of staff receiving regular formal supervision no less than 6 times a year. All accidents must be recorded 31/12/05 accurately and must include all of the required information. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP11 Good Practice Recommendations 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. DS0000012950.V263157.R01.S.doc Version 5.0 Page 21 Wendleberrie House Wendleberrie House DS0000012950.V263157.R01.S.doc Version 5.0 Page 22 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.V263157.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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