Inspection on 02/12/05 for Wendorian

This inspection was carried out on 2nd December 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wendorian 28/11/06

Wendorian 05/05/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Wendorian Cracknore Hard Lane Marchwood Southampton Hampshire SO40 4UT Lead Inspector Ms Wendy Thomas Unannounced Inspection 2nd December 2005 03:00 Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 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 Wendorian DS0000060604.V266248.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 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. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wendorian Address Cracknore Hard Lane Marchwood Southampton Hampshire SO40 4UT 02380 867557 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) wendorian@ukonline.co.uk Wessex Regional Care Limited Mrs Charlotte Hemphill Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Wendorian is a service for five clients who have learning disabilities and may also present behaviour that is challenging to service providers. It is situated in Marchwood a short distance from local shops and a within easy walking distance from the Solent. Wendorian is part of Wessex Regional Care Ltd. who have two other homes in the Hampshire area. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The people living in the home wished that the inspector refer to them as clients when writing this report. This term is therefore used throughout the report. The inspector visited the home between 15:00 and 19:30. There are currently three clients living in the home. The inspector spent time with them as a group and also with individuals who showed the inspector information about themselves, their rooms and their medication. Time was also spent with staff and examining service users’ files and a sample of the home’s policies and procedures and health and safety records. What the service does well: What has improved since the last inspection? The hallway and landing have been repainted and are much more in line with the tastes of those living in the house, who said that they were involved in deciding the colour scheme. They had also been involved in the colour scheme in the newly painted lounge, and in choosing the new lounge furniture that was on order. A newly built conservatory provides more communal space and the opportunity to divide it from the lounge/diner. A small activity room has also been built in the garden. One of the clients described using this for relaxation. There is also a computer there for the clients to use. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 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. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 7 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 Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 8 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): 2. Careful consideration of the compatibility of potential clients with the current clients promotes the selection of new clients who will fit successfully into the home. EVIDENCE: Since the last inspection one of the clients has moved on to more independent living, and a fifth bedroom has been registered at the home. There are, therefore, two vacancies. It was reported by staff and clients that someone was currently being considered for one of these places. The registered manager informed the inspector that a pre-admission assessment has been thoroughly completed by senior managers, but this was not available in the home at the time of the inspection. She stressed the importance of having the correct information to ensure that the home could meet the person’s needs, and the need for them to be compatible with the current clients. The person is known to some of the clients who seemed happy at the prospect of them moving to the home. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 9 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 and 9. Given the potential for challenging situations some service user plans do not give sufficient information about triggers and strategies for these to be approached in a consistent way. A procedure detailing how risk assessments are carried out, and regular review of clients’ risk assessments and strategies, could provide greater safeguards for clients and opportunities for their development. EVIDENCE: The inspector looked at the service user plans for two service users. Comments made in the previous inspection report regarding service user plans still stand, in that there were still notable omissions such as what form the “untoward incidents” referred to in one client’s file took, or what the “known triggers” for these were. This had not improved since the previous inspection. Risk assessments gave fuller information but those seen had been drawn up almost a year before and despite having three-monthly review dates planned in, there was no record of these reviews having taken place. Records showed Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 10 that clients’ individual support plans were being reviewed at the regularity the home had set itself, i.e. monthly. “Personal profiles” had been developed. These gave useful information about the clients, but again omitted mention of the possibility or form of challenging behaviour. Clients have files in their rooms which they developed with their key-workers giving information about themselves. All three showed these to the inspector. The manager explained that staff from the organisation would shortly be undertaking training in person centred planning, and it was planned that they would use this experience to develop the service user plans further. The risk management policy in the home’s file was seen. This explained the rationale behind assessing and managing risks, but did not detail how this was to be done in the home. It is recommended that this be included. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 11 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 and 17. Clients benefit from having lots of opportunities to participate in activities in and out of the home. Clients are enabled to take part in choosing, cooking and shopping for their meals. EVIDENCE: The clients told the inspector about the activities they were involved in. These included college courses, work opportunities, various day services, and dancing lessons. They also described helping with the household shopping, cooking and gardening. There had also been one off trips, described by the service users, staff and in service user records, to the Tutankhamen exhibition in Dorchester, Christmas shopping in Southampton, ice skating, a visit to Lyndhurst, an evening at a night club, and trips to the pub. One client had been on an activity holiday with their day service and another had been to Spain with a relative. One client has a season ticket, and supports a local football team. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 12 The inspector talked with the clients about the food. They said that the food was good, but that as they were all hoping to become more independent they would like to help to prepare the meals more often and not just help with the clearing up. This was raised when the deputy manager joined the group and they agreed that they were each helping about once a week at the moment. The clients said that they were involved in deciding what to eat. When the inspector arrived for the inspection the preparations for the home’s first anniversary party were just being completed. Lots of party food and a special cake had been prepared. By the time the inspector left guests from the organisation’s other homes, clients’ friends, families and supporters were arriving for the celebrations. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 13 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): 20. Greater coherence between the medication policy and the procedure would provide greater protection to clients. EVIDENCE: The inspector viewed the medication policy in the home’s policy file. This was of good quality, however it did not include details of how medication was disposed of when necessary. This should be included. As well as the medication policy there were also guidelines to staff on how to administer medication in the home’s “pharmacy” file. Some aspects of this did not mirror what was written in the policy. It was advised that the two should be describing the same procedure. Two of the clients, with a member of staff, showed the inspector their medication cabinets and described how medication was administered. Records showed that all medicines had been taken and signed as taken. The home should liaise with the pharmacy or GP to ensure that detailed administration details are recorded on the monitored dosage boxes and the medication administration sheets. In some cases the instructions were “as directed”. This is insufficient. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 14 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 and 23. Clients benefit from a client centred ethos of the home where their views are taken seriously. Training and policies ensure that opportunities for abuse of clients are minimised and appropriate action would be taken if such an incident occurred. EVIDENCE: Clients were not sure that they had a copy of the complaints procedure, however upon being reminded of their whereabouts by the deputy manager a client was able to locate theirs in a pack about the home including the service user’s guide and contract etc. and showed it to the inspector. It gave the lines of accountability, including photographs, for making a complaint. The clients said that they like having the fortnightly clients’ meetings and are able to raise matters that concern them there. They are consulted on most matters relating to the running of the home. The home has a copy of the organisation’s abuse policy. There was also a copy of Hampshire’s procedure on protecting vulnerable adults from abuse as well as leaflets displayed on the office notice board summarising the Hampshire procedure for clients and staff. It was reported that staff attended internal training on the protection of vulnerable adults. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 15 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. Clients benefit from a comfortable home, in which they have been involved in selecting furnishings and décor. EVIDENCE: Since the last inspection the activity room in the garden has been completed and a conservatory added to the back of the house. The old activity room has now been registered as a bedroom. Everyone expressed satisfaction with the conservatory, which provides another communal area in addition to the lounge/dining room. One client described using the activity room for regular structured relaxation sessions. Following discussion at the previous inspection the hall and landing had been decorated achieving a marked improvement. The clients told the inspector how they had chosen a new suite for the lounge from a catalogue. The inspector was also informed that the clients had chosen the furniture for the conservatory. It was expected that all the furniture would be delivered shortly. One client said that they would be taking the old armchair into their bedroom. The lounge had been redecorated and the clients said that they had chosen the colour scheme and a new rug for the floor. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 16 All three clients showed the inspector their bedrooms and expressed their satisfaction with them. Two said that they had had theirs decorated to their choice. The third said that they were hoping to have theirs decorated soon. They had chosen to move into the room vacated by the client who had moved on. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 17 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 and 34. The organisation supports staff development, thus promoting the development of skills that will benefit the clients they are supporting. A recruitment process outlines how staff are identified to support clients’ needs. EVIDENCE: The thing that all clients said they had the most difficulty with was getting used to new staff and staff leaving. They estimated that between five and seven staff had changed over the year the home had been operating. The manager said that they were interviewing again for new staff the day following the inspection. The clients told the inspector that they were not involved in staff selection. They expressed an interest in being involved and one said that they had interviewed staff for another organisation they were involved with. They all described the staff that had been employed so far by the home as “OK” and agreed that they did a good job. One client described how, when they had been ill in bed, staff checked on them regularly, which had reassured them. The inspector was not able to see the home’s staff files on this occasion as the records were locked away. However, she viewed the recruitment policy which described the process in seven bullet points including, obtaining an application Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 18 form, references, Criminal Records Bureau check, a visit by the applicant to the home, an interview, the issuing of terms and conditions of employment and details of probationary period. The manager described critically assessing the recruitment process to refine it on order to improve the identification of personnel with the desired attributes for working in the home. The manager discussed her frustration over the organisation with whom five staff had been signed up to begin their NVQ level 2, deciding at the last minute not to offer the course. One member of staff was currently doing NVQ 3, but it was proving difficult to get staff on to courses in the area. She said that what courses are available, have long waiting lists. She described how the organisation was developing a twelve-week induction programme that will cover a number of the NVQ units. These would be assessed by an internal assessor, with only a few units needing to be taken externally to achieve NVQ level 2. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 19 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, 40 and 42. Clients benefit from and effectively run home, and value being involved in, and consulted about, the running of the home. Improvements to some policies will give clients greater protection and clarify procedures used in the home. The home’s consideration for clients’ and staff’s health and safety benefits all who live and work there, however prompt action is needed when health and safety risks are identified. EVIDENCE: Although the management responsibility for the home remains with Charlotte Hemphill, the registered manager, her promotion to area manager means that the organisation is looking to recruit someone to take on the day-to-day management of the home and become the registered manager. Charlotte is qualified to NVQ level 4 and has the Registered Managers Award. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 20 The manager has previously discussed with the inspector her philosophy of fully involving the clients in the running of the home and in decision making for themselves and the home. The clients confirmed that this was happening, although there were some areas where they were unsure why things were happening in the way they were e.g. staff selection and the reallocation of keyworkers. They were, however, able to explain to the inspector the reasons why a member of staff was no longer working in the home, as this had clearly been discussed with them. They valued the two to four-weekly clients’ meetings held in the home and supported by staff. Through these they felt very involved in the running of the home. Minutes of the meetings are kept. The home’s statement of purpose states that it works with service users with challenging behaviour. The inspector would therefore have expected to see policies relating to working with the particular needs of this client group. There was no such policy available. There was a two-page policy regarding the use of physical intervention. This did stipulate that restraint should be the last resort, but did not refer staff to the client’s service user plan to determine when that last resort had been reached for each individual, and the personalised strategies to be used with the different clients. Work is needed in this area to ensure that staff’s response to clients is in line with the clients’ needs and that safeguards are in place for clients as well as staff. The inspector sampled other policies, including medication, recruitment and risk taking and risk management (all commented on elsewhere in this report), and whistle blowing. Possible changes to the whistle blowing policy were discussed with the deputy manager. Health and safety checks were sampled and were found to be satisfactory, however a faulty fire-door closure had been outstanding for several weeks and could put clients at risk if a fire were to break out. The deputy manager reported that the home’s maintenance contractor had been requested to attend to this. However, the risk issues involved necessitate this being dealt with urgently. The inspector noted that health and safety risk assessments were in place. One had not yet been written for the newly acquired portable gas heater in the conservatory. The deputy manager gave assurances that this would be done. The hot water in the washbasins was very not. It is suggested that this should be risk assessed. The bath water did not have thermostatically controlled valves, however there were risk assessments in place for two clients stating that they used a thermometer to ensure that the water was not going to be too hot of them. One should also be prepared for the third client. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wendorian Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 X 2 X DS0000060604.V266248.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation Requirement Timescale for action 24/02/06 2 YA42 15,13(6,7,8) The form the service users’ challenging behaviour takes and the strategies for meeting these needs must be included in their service user plans. 23(4). The faulty fire-door closure must be repaired/adjusted to operate effectively. 30/12/05 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. 3 Refer to Standard YA9 YA20 YA40 Good Practice Recommendations Risk assessments should be reviewed in accordance with the home’s policy. The medication policy should include details of the disposal of medication. Policies and procedures should be developed in relation to working with people with challenging behaviour and policy regarding physical intervention should be further developed. Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Wendorian DS0000060604.V266248.R01.S.doc Version 5.0 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. 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