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Inspection on 15/11/05 for Wentworth Croft

Also see our care home review for Wentworth Croft for more information

This inspection was carried out on 15th November 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Wentworth Croft Bretton Gate Peterborough PE3 9UZ Lead Inspector Elaine Boismier Announced Inspection 15th November 2005 11:00 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 Wentworth Croft DS0000024308.V254919.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. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wentworth Croft Address Bretton Gate Peterborough PE3 9UZ 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) 01733 269200 01733 269665 BUPA Care Homes (CFHCare) Ltd Mr Alan Bristow Care Home 134 Category(ies) of Dementia - over 65 years of age (39), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32), Old age, not falling within any other category (125), Physical disability (2), Physical disability over 65 years of age (58), Terminally ill over 65 years of age (58) Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. Two named individuals with Physical Disabilities who are below 65 years of age (PD) for the duration of their residency No more than 92 beds to provide nursing care Service users who are over 65 years of age, not falling within any other category (OP) not exceeding 125 places for the duration of Condition 1 & 8 Terminally ill over 65 years of age (TI(E)) not exceeding 58 places for the duration of Condition 1 Physical disability over 65 years of age (PD(E)) not exceeding 58 places for the duration of condition 1 & 8 Mental disorder, excluding learning disability or dementia over 65 years of age (MD(E)) not exceeding 32 places Dementia over 65 years of age (DE(E)) not exceeding 32 places. The maximum number of persons accommodated in the home at any one time is 134 7 named individuals over 65 years of age with dementia for the duration of their residency only (DE(E)) 23rd August 2005 Date of last inspection Brief Description of the Service: Wentworth Croft is situated in Peterborough City 4 miles from the city centre and is accessible by public transport. The home is situated in well-maintained and landscaped gardens including an enclosed garden for those living at Harvester House. Wentworth Croft is arranged into 4 houses: Yeoman and Hayward provide up to 60 places for people over 65 years of age who have nursing needs; Harvester provides up to 32 places for people over 65 years of age with both nursing and mental health needs; Woolsack provides up to 42 places for people over 65 years of age with personal care needs. The Commission for Social Care Inspection has approved variations of registration for 2 named people below 65 years of age with personal care needs and 7 additional people, over 65 years of age, with mental health needs, to live at the home. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the third inspection of Wentworth Croft for 2005/6. The inspection was announced and carried out by two Inspectors between 11:00 and 15:30 and took 4.5 hours to complete. Prior to the inspection the Commission received 40 completed relatives’/visitors’ comment cards and 15 completed service users’ comment cards. In addition the Commission has received a letter and telephone call from two individual relatives of residents living at Wentworth Croft. Hayward House, Harvester House and Woolsack House were visited during this inspection. There were 133 residents living at the home and 7 of these were spoken to. The Registered Manager, staff and four visiting guests of residents were spoken to also. Documentation was seen and a tour of the premises was made to complete the inspection process. The Registered Manager has agreed to confirm, in writing, to the Commission the current number, categories and spent conditions of registration for a new certificate of registration to be issued. What the service does well: • • 100 of residents in the service users’ completed comment cards said that they felt safe living at Wentworth Croft. 100 of residents in the service users’ completed comment cards said that they felt staff treated them well and 93 considered their privacy was respected by staff. 83 of relatives’/visitors’ in the completed comment cards said that they were satisfied with the overall care. 93 of relatives’/visitors’ in the completed comment cards said that they felt that Wentworth Croft welcomed them at any time to visit their relative/friend living at the home. Residents and relatives/visitors made positive comments to the Inspectors about staff, including,“ Staff work very hard and do a marvellous job.” Residents made positive comments about the food provided. • • • • Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 6 • • • Robust systems are in place for listening to complaints Robust systems are in place to protect and reduce the residents from abuse. There is a commitment in making Wentworth Croft a homely, and more private, place for residents to live. What has improved since the last inspection? Following the inspection of 23rd August 2005 two requirements were made. There has been improvement in both these areas. • A requirement was brought forward from the 1st inspection of Wentworth Croft for 2005/6. This requirement was that the Registered Person must ensure that the independence of residents was respected to promote the value of dignity. Observation of staff and comments made by residents indicate that this requirement has been met. A requirement was made for the standard of cleanliness on Hayward House to be improved. At the time of the inspection the general cleanliness of Hayward House was satisfactory. This requirement is considered met. • What they could do better: The home could improve in 3 noticeable areas: • Information about prospective residents must be in sufficient detail to ensure the home is suitable in meeting the needs of the person. A requirement has been made about this. Medication must be kept in a safe manner. An immediate requirement has been made about this serious concern. A review of the changing needs, and the dependency levels of residents on Harvester House should be considered to ensure that the number of staff provided is sufficient. A recommendation has been made about this. • • Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 7 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. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 8 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 Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 9 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 Lack of detailed pre-admission information poses a risk that the home might not be able to meet the needs of residents. EVIDENCE: Discussion with staff on Hayward House indicated that pre-admission information provided via telephone and written communication, is not always sufficient in detail for the home to make an accurate assessment if the prospective resident’s assessed needs can be met. Staff considered that they were unable to meet the specialist needs of at least one of the current residents, assessed to have rehabilitation needs. A requirement has been made about this finding. Wentworth Croft DS0000024308.V254919.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): 8, 9 & 10 Residents’ care needs are met and are provided in a private and dignified manner although methods of storage of medication pose a risk to residents’ health and safety. EVIDENCE: The majority of residents (87 ) stated, in the returned comment cards, that they felt well cared for and 13 of residents, in the returned comment cards, considered they were well cared for “sometimes”. The majority of relatives and all residents spoken to at the time of the inspection considered that the care provided was of a good standard. Residents on Hayward House reported that staff encouraged them, to maintain their level of independence as much as possible. This was observed also during the visit to Harvester House where a member of staff was noticed to encourage a resident to eat his lunch in an independent manner. As a result of these findings this requirement has been met. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 11 During the tour of Hayward House three bedrooms were found to have medication kept in unlocked rooms and accessible to any person visiting the room. As a result of this serious issue an immediate requirement has been made. Residents made positive comments about staff attitudes and 100 of residents in the service users’ completed comment cards said that they felt staff treated them well. A relative/visitor wrote in a comment card, “ People are extremely friendly. Staff ask people how they are feeling if one has been unwell.” During the tour of Harvester House it was noted that, since the last inspection, and at the request of relatives, locks have been provided on bedroom doors. Of the 15 returned service users’ comment cards, 93 of the responding residents considered their privacy was respected by staff. Wentworth Croft DS0000024308.V254919.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): 13 & 15 Residents’ social care needs are generally well met. EVIDENCE: The majority (93 ) of relatives/visitors considered that the home welcomed them to visit at any time. On the day of the inspection it was noted that some residents were receiving guests both in lounges and in bedrooms. 80 of residents’ completed questionnaires indicated that the residents liked the food and 20 of residents’ completed questionnaires indicated that the residents liked the food “sometimes”. Those residents spoken to stated that they enjoyed the food. Wentworth Croft DS0000024308.V254919.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 Residents and their representatives are listened to and systems are in place to protect residents from abuse. EVIDENCE: During the tour of the three Houses it was noted that clear information is available on how to make a complaint. The record of complaints was seen and this was satisfactory. The home has taken action in response to relatives/representatives concerns. This includes replacement curtains and the provision of locks on bedroom doors. In response to a small number of written comments, made by relatives/visitors to the Commission, about the standard of care of resident’s personal clothing, 6 bedrooms were visited. This was to assess the condition of storage and labelling of residents’ personal clothing. All rooms visited had items of clothing put in drawers in a tidy manner; socks were put together in pairs and garments were labelled and belonging to the resident of the particular room. The home has demonstrated robust reporting procedures, and has taken appropriate action, when allegations of abuse have been made, to reduce the risk of harm to residents. Wentworth Croft DS0000024308.V254919.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 & 26 Residents live in a safe, clean and homely place. EVIDENCE: During the tour of the three houses it was noted that replacement curtains have been provided and décor and furnishings, in bedrooms and communal areas were of a good standard. 100 of residents’ completed comment cards indicated that residents felt that Wentworth Croft was a safe place to live in. On Woolsack House improvements have been made of a small enclosed garden area. The Unit Manager, of Woolsack, reported that residents have enjoyed visiting this area, especially during warmer weather. A requirement was made for the standard of cleanliness on Hayward House to be improved. On the day of the inspection all three Houses, including Hayward House, were clean and free of offensive odour. As a result of this finding this requirement has been met. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 15 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 Residents’ needs are met by sufficient number of staff although this might not always be the case. EVIDENCE: 47.5 of relatives’/visitors’ comment card stated that staffing levels were satisfactory; 52.5 of relatives’/visitors’ comment card stated that staffing levels were not satisfactory. Examination of the staff roster for a two-week period for Harvester House indicated that there was sufficient number of staff on duty at all times. However staff and a relative spoken to, on Harvester House, suggested that, due to fluctuating and changing needs of residents, there were occasions when an increase of the number of staff was needed. On the day of the inspection there was sufficient number of staff on duty; residents were calm and staff were meeting the needs of the residents at lunchtime-a busy period of the day. Due to the lack of clear evidence that there is an insufficient number of staff a recommendation has been made for the home to consider carrying out a review of the dependency levels of residents living on Harvester House to ensure that there is a sufficient number of staff to meet the reported residents’ fluctuating and changing needs. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: None of these standards were assessed on this occasion. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 17 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 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 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 18 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 OP3 Regulation 14(a) Requirement The Registered Person must ensure that a suitably qualified person, to ensure that full information is provided, has assessed the needs of the service user. The Registered Person must ensure the safe storage of medication. Timescale for action 22/11/05 2 OP9 13(2) 15/11/05 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 Refer to Standard OP27 Good Practice Recommendations The Registered Person should consider methods make sure that the number of staff provided is sufficient to meet the needs of service users. Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Wentworth Croft DS0000024308.V254919.R01.S.doc Version 5.0 Page 20 - 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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