Inspection on 06/12/06 for Wensley House

This inspection was carried out on 6th December 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

Wensley House 22/10/08

Wensley House 23/10/07

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE Wensley House Bell Common Epping Essex CM16 4DL Lead Inspector Sarah Hannington Key Unannounced Inspection 6th December 2006 12:00 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 Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 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. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wensley House Address Bell Common Epping Essex CM16 4DL 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) 01992 573117 01992 560479 Beling & Co. Ltd Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 31 persons) Date of last inspection Brief Description of the Service: Wensley House is a fully detached two storey building on the outskirts of Epping Town, close to Epping Forest and backing on to Epping Cricket Ground. Nearest shopping facilities are in the town of Epping. Public transport passes close by the home. The home is registered to accommodate thirty-one elderly people (over the age of 65). Accommodation is provided in twenty-one single bedrooms and five shared bedrooms, situated on both floors of the home. Communal space comprises of a conservatory, one dining/sitting room, a further small dining room and one lounge all on the ground floor, there is also a lounge/dining room on the first floor, which is designated as a visitors lounge. Access between floors is provided by a passenger shaft lift. The home is reached by a long private driveway leading to ample visitor car parking to the front of the building. Fully accessible, well maintained, gardens are provided for residents to the front, side and rear of the property. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the Inspection the acting manager of the home and the proprietor were present throughout the inspection process. A tour of the home took place and Staff, relatives and residents were spoken with during this inspection. The Key inspection site visit took place over a period of 6.5 hours. The visit mainly focused on the all Key standards. In addition, Information was also taken from the pre-inspection questionnaire submitted by the Registered Provider. This unannounced inspection was the first inspection of this home since being registered in 2006. What the service does well: 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. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 6 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 Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 7 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): 3&6 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are given a service user guide which informs them of the services provided and they also are encourage to visit Wensley House prior to any admission. This allows prospective residents and there families make an informed choice as to whether or not Wensley House will met their needs. EVIDENCE: All care plans included initial assessments carried out prior to admission. All care plans are presently being re-organised and will give a comprehensive break down of each resident needs including associated risks. The home does not provide intermediate care. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 8 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): 7,8,9 & 10 Quality in this area is adequate. This Judgement has been made using available evidence including a visit to this service. Care Plans are in the process of being re-organised to reflect and highlight all residents’ individuals’ needs. The care plans will include all aspects of an individuals needs and there has been progress made in this area, however they still need further development. The review of clients care plans is evident. EVIDENCE: On inspection of five care plans these were inconsistently completed with some elements of the care plan containing relatively detailed and informative information, whilst other elements lacked specific detail. A new care plan format/risk assessment system is to be implemented in due course and all current care plans to be reviewed and rewritten. Daily care records were written each day. However evidence of staff’s interventions to deal with certain situations and information relating to specific support given to residents was limited in some cases. Risk assessments need to clearly evidence that all parties, such as a multidisciplinary team, residents, advocates, families have agreed the action that may restrict or infringe on an individuals rights. This type of risk assessments need to be developed further so that it clearly records, evidences and shows that consultation with all parties involved had gone ahead and had all agreed to the final outcome of action to be taken. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 9 Rapport and interaction between residents and care staff was observed to be positive. Staff spoken with demonstrated an awareness of resident’s needs. The home’s storage arrangements for medication were satisfactory. The acting manager and all team leaders are appropriately trained to administer medication. No omissions were observed within the medication administration records (MAR). Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 10 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): 12,13,14 & 15 Quality in this area is poor. This Judgement has been made using available evidence including a visit to this service. There are no activity plans for each individual; activities in general still need further development. Relatives and friends are encouraged to have regular contact with the home. A variety of regular nutritious meals were being provided. EVIDENCE: The home does not have activity co-ordinators. No specific programme of activities for residents was available and information documented within individual care plans detailing activities undertaken by residents indicated infrequent activities/meaningful stimulation offered and/or provided. It was evident during the inspection that care staff and senior staff are very busy with providing personal care to residents and do not have specific time available to initiate activities for residents. Staff spoken with were disappointed that this element of care could not be provided on a regular basis. One relative spoken with stated that they were equally disappointed that there is a lack of activities available within the care home. During the inspection time was spent touring the building and chatting to individual residents, it was clear that the staff on duty are making the use of the time they have to carry out the many practical duties they have to fulfil. Residents spoken with on the day of inspection had expressed they wanted activities to be put into place and one resident had stated to me that even though they may not join in, they would like to observe and have some stimulation. Another commented that they would like someone to come into the home to play the piano that sits in the lounge. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 11 Staff was seen to be consulting and asking service users permission before going into peoples bedrooms. Service Users rooms were personalised and clean with free from odours. Residents and relatives spoken with spoke highly of the staff team and felt that the acting manager and staff in general were approachable friendly and caring. Relatives and residents also informed me that they could have visits at any time and were made to feel welcome. During Inspection lunchtime was observed and it was noted that the residents were encouraged to have a choice of foods available that day. Menu’s need to be developed further to evidence what foods are offered, to track individual nutrition and fluid intake clearer than it is presently. On the day of inspection residents were asked about the food provided and were very complementary about the food provided, the way it was served and how staff supported them during meal times. Food smelt and looked appealing and was presented nicely. Both meal times were unrushed and had a relaxed atmosphere. Staff was seen supporting residents discreetly to eat meals. Staff were also seen to encourage other residents to use their limited skills by letting them eat unhurried and not worrying about mess caused by allowing them to maintain this independence. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 12 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 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and each service users and relative has. A service users guide that highlights the complaints procedure. The homes policy and procedures and training of staff appear to protect residents from abuse. EVIDENCE: No complaints or Protection of Vulnerable Adults issues have been highlighted since being registered. Staff training records evidence that staff have received Protection of Vulnerable Adults training. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 13 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 & 26 Quality in this area is adequate. This Judgement has been made using available evidence including a visit to this service. On the whole the outside environment is pleasant, attractive and provides appropriate and practical usage for the residents of Wensley House. The home environment provides a clean, comfortable and safe environment in which to live in. EVIDENCE: Furnishings in the home looked comfortable and areas of the premises seen were very well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared safe. Numbers of toilets and bathrooms are sufficient, however there are a large number of bathrooms not in use due to individuals mobility and support needs. The home needs to develop bathing facilities and the proprietor is going to address these issues as part of his business plan for the home. The home was clean and considered to be hygienic. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 14 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): 27, 28,29 & 30 Quality in this area is adequate. This Judgement has been made using available evidence including a visit to this service. The number of staff on duty, their experience and skill was able to meet the basic needs of residents, however activities need to be developed further. Recruitment records were in place and to a good standard. Staff have had mandatory and specific client related training and further training is planned throughout this year. EVIDENCE: Rota’s evidenced that cooking, domestic and laundry provided by additional staffing. There was also a maintenance person employed. Apart from the care staff Individualised activities need further development and a separate role for activity co-ordinators need addressing. No specific programme of activities for residents was available and information documented within individual care plans detailing activities undertaken by residents indicated infrequent activities were provided. Staff recruitment records evidenced that application forms were completed, interviews were held, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. Contracts of conditions of service and job descriptions were issued to new staff. Copies of training certificates were also kept on staff files. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 15 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): 31,33,35 & 38 Quality in this area is good. This Judgement has been made using available evidence including a visit to this service Financial practices in the home appeared to have been competently managed. The health and safety of residents and staff appeared to be assured. EVIDENCE: Relatives support all residents regarding their personal financial management. The home only holds sums of monies for personal allowance expenditure. Relatives provide this. Records of payments and balances had been kept and random samples inspected were found to be appropriately maintained at the time of this inspection. Staff training records confirmed that training courses are provided in moving and handling, fire safety, food hygiene, first aid and infection control. The homes policy on the control of substances hazardous to health (COSHH) included data action sheets. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 16 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 17 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 OP12 Regulation 16 (2)(m)(n) Requirement The registered person must ensure that suitable arrangements are made for all residents to receive a varied programme of `in house` and community based activities. The registered person must ensure that there are suitable staff ratios for all residents to receive a varied programme of `in house` and community based activities Timescale for action 28/02/07 2 OP27 18 (1) (2) 28/02/07 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 OP28 OP33 Good Practice Recommendations 50 of care staff should achieve NVQ Level 2 The registered person must ensure that the quality assurance system action plan is forwarded to the CSCI. Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 18 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Wensley House DS0000066442.V313151.R01.S.doc Version 5.2 Page 19 - 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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