Inspection on 18/06/07 for Wentworth Hall

This inspection was carried out on 18th June 2007.

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

Wentworth Hall 20/12/05

Wentworth Hall 23/06/05

Wentworth Hall 25/10/04

Wentworth Hall 27/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Wentworth Hall Church Drive Wentworth Rotherham South Yorkshire S62 7TW Lead Inspector Valerie Hoyle Key Unannounced Inspection 18th June 2007 09:15 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 Hall DS0000003110.V329145.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. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wentworth Hall Address Church Drive Wentworth Rotherham South Yorkshire S62 7TW 01226 748618 01226 748618 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) Mr Paul Wilson Crabtree Mrs. Gloria Crabtree Lisa Carpenter Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Wentworth Hall is situated on the outskirts of Rotherham in a small rural village. Amenities close to the home include a small village shop, post office and two public houses. Access to the home is via a drive that also leads to the local Church. The home is a converted building with the original staircase that leads to the first floor accommodation. Service users can also use the passenger lift to access bedrooms. The home provides accommodation for 23 service users who fall into the older persons category. The personal space includes single rooms with en suite, and a small proportion of rooms that can accommodate two service users. There are a number of lounges and a conservatory that overlooks the gardens. The gardens are well kept and there is a small pond and fountain as the main feature. The home provides information to service users and their relatives prior to admission into the home. Service Users Guides are available in all bedrooms or on request from the manager. The last published inspection report is available on request and a copy is available in entrance for visitors to read. Information gained on the 18th June 2007 indicates the current fees range from £349 to £370. Additional charges include private chiropody £6, hairdressing from £2.50 - £15.00, and newspapers and transport. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over 6 hours, this included a partial inspection of the building. Three peoples care plans and supporting documentation were examined. Seven people who use the service, three relatives and four staff were spoken to during the visit, their views are included throughout the report. Occupancy at the home remains high with 22 of the 23 beds occupied. Five CSCI service users questionnaires were sent to the home and four surveys were returned. Four staff questionnaire was returned, and one health and social care professional survey was returned. The information has been collated and their views are contained within this report. The registered manager was present throughout this visit and assisted with the inspection process. The registered manager had completed and returned the pre-inspection questionnaire and the information gained is included in this report. What the service does well: The home is well managed ensuring the safety and protection of people who use the service. There is a stable staff group who have worked at the home for a good length of time, and they spoke positively about improving the standard of care to enhance the homes reputation within the community. People spoke positively about living at the home, and said the staff made them feel safe and well cared for. One person said the move into the home had changed their life, from being lonely to having lots of people to talk to. People say the activities are arranged to meet their needs. Regular visitors include the local church and people who play music and organise exercise to music. Other popular activities include crafts and bingo. People’s medication were well managed to ensure they receive their medication as directed. Recruitment procedures are robust which ensure the safety and protection of people who use the service Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 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 Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs can be met. EVIDENCE: All new people receive a full comprehensive needs assessment before admission this is carried out by manager or responsible person who have the required skills and competencies. The service is highly efficient in obtaining a summary of any assessment undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. Staff confirmed that information contained in the assessment was essential to understand what they needed to do to ensure people’s needs were met. Three assessments were examined and they focused on achieving positive outcomes for people who use the service. Before agreeing admission the Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 9 manager and staff carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective people who use services were given the opportunity to spend time in the home, before making final decisions about where to live. One person who had lived at the home for only a few months said family had been to look around before choosing it to be the home where she/he would live. All CSCI surveys received confirmed that people who use the service were provided with sufficient information about the service before moving into the home. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide staff with sufficient information to meet the needs of people who use the service. Arrangements for dealing with health issues are met with support from health professionals. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Three care plans were examined; these were well written and provided sufficient information to enable staff to meet the needs of the people who use the service. The staff continues to support one person who is displaying some agitated behaviour, although some care plan documentation needed to be reviewed to enable staff to provide appropriate means of intervention. The care plans include regular evaluations, and daily records assess the individual’s progress. Comprehensive risk assessments ensure people can maintain their independence, while remaining safe. All CSCI surveys received confirmed that Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 11 people’s needs were always met by staff that were well trained. Surveys say that staff always listens to people who use the service, and people said staff were excellent, well trained and always provided a good service. Records examined and discussion with the staff confirmed people’s healthcare needs were met. The manager said doctors provide a good service, and staff were trained to recognise health problems and report them to the nurse in charge of the shift. One professional CSCI survey received confirmed that staff always provides a good standard of care. An audit of medication stocks and records were examined and were found to be correct ensuring the health and safety of people who use the service. Senior carers had responsibility for administering medications and they had attended training to update their knowledge, to ensure medicines were administered safely. The local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. Medication was stored securely, there were separate, locked rooms for storing medication that contain a locked fridge and a controlled drugs cabinet. Throughout this visit staff were seen interacting with people who use the service in a kind manner, they spent time talking to people and were observed knocking on bedroom doors before entering. All people were referred to by their first name and this was agreed in the care plans examined. CSCI service user surveys received confirmed that staff always treated people who use the service with respect and maintain their dignity at all times. Relatives praised staff and said nothing was ever too much trouble, to ensure their family was cared for in a kind sensitive manner. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities are organised which are appropriate to the needs of the people who use the service. Mealtimes were well managed and people were encouraged to make choices and control over their own lives. People who use the service can maintain contact with family and friends, and have good opportunities to maintain links with the local community. EVIDENCE: There was a warm and friendly atmosphere on entering the home and a sense of wellbeing throughout the home. Staff are commended for creating a pleasant ambiance in the lounges. People who live at the home said activities and outings were very good. The local church plays a important role within the home with regular visits from the clergy and a weekly visit from a lady who plays music. Entertainers are also brought in a various times of the year and staff often take people who live at the home into the local village. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 13 One person with a particular interest in gardening said he/she enjoyed growing tomatoes in the green house, and was looking forward to seeing the crop on the menu for tea. There was a calm environment throughout this visit with some service users spending time in their bedrooms, while others spent time in the various communal areas. A partial tour of the building found many examples of how service users are encouraged to bring in personal items to help them feel at home. Visiting relatives said they were always made to feel welcome and staff were very caring. They also said that they were confident in staff’s ability to provide the care needed for their relative. The cook gave examples of the menus provided and said alternatives were always available. Staff asks people what foods they liked and the meals were included in the menus. The meals were served to the dining areas direct from the kitchen, and the meal was served with a choice of hot and clod drinks. Mealtimes were well managed by staff who have a good understanding of peoples dietary needs. Staff were seen giving assistance in an unobtrusive way, and meals served to people in their bedrooms were accompanied with a drink. People said they had enjoyed their meal and confirmed the quality was very good and plentiful. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can access the complaints procedures and the manager ensures any concerns are recorded and investigated appropriately. Adult protection policies, procedures and training of staff promote the protection of service users from abuse. EVIDENCE: There is a complaints procedure that is available to people who use the service and visitors. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure, although the address needs to state the CSCI Sheffield office details. Examination of the complaints records show that there were no complaints recorded since the last visit to the home. People who use the service said that they are confident that the manager or the responsible person would deal with any concerns they may have. There is a comprehensive Adult Abuse and Whistleblowing policy and staff follow the procedures to those standards. The registered manager would investigate fully any allegations of abuse and would follow the necessary procedures if any were substantiated. The registered manager holds discussions with staff to talk over issues and how to recognise different forms Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 15 of abuse, although training records indicate that formal training on the protection of vulnerable adults is required. Recent issues regarding the management of one person who uses the service had identified shortfalls in polices and procedures relating to the management of missing persons, and how staff deal with challenging behaviour and restraint. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are provided with a clean, comfortable environment, although some refurbishment is planned to improve the conservatory. There were sufficient staff to maintain good hygiene standards. EVIDENCE: The registered providers continue to make improvement to the fabrics and furnishings at the home. Bedrooms are generally decorated as they become vacant. A government grant had been obtained to refurbish the conservatory, which will include replacing the roof and creating a new paved area making access to the garden easier. The home is situated along the driving the way that leads to the local Church and is in a quite rural setting. Trees surround the gardens and there is an Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 17 enclosed garden at the rear of the building. There is an attractive pond as the main feature of the garden and this has a water feature in the centre. People who live at the home enjoy spending time in the garden and one service user spends her/his time feeding the birds and wildlife. The home was clean and free from offensive odours and service users said that their bedroom was always kept clean and tidy. The domestic staff are commended for their efforts in maintaining the cleanliness of the home. CSCI surveys confirmed that cleanliness was always of a high standard. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff had the skills and knowledge to fulfil their roles within the home; a stable staff group ensures continuity of care by staff that knows the people who use the service. Recruitment policies are followed ensuring the safety and protection of people who live at the home. EVIDENCE: Training records examined show some refresher training (infection control, moving and handling, food hygiene, health and safety) was required to ensure staff have the competencies to deliver a good service to people who live at the home. Discussion with the manager and staff confirms that there was a stable staff group who had worked at the home for a good number of years. Staff say they enjoy working at the home, and feel supported. There was a robust induction and probationary package, which was service specific. The manager only confirms permanent employment when satisfied that competence and progress has been shown to be satisfactory against their high standards. Staff rotas and observation during this visit show there were sufficient staff to meet the needs of people who live at the home. Staff were deployed to work Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 19 on the three floors of the home, which ensures people are safe and well looked after. Staff had the required skills to meet the needs of people, and they are commended for meeting the requirement of 50 NVQ level two qualified staff. A number of staff are progressing with or completed NVQ level three. There were robust recruitment and selection procedures that ensure people who use the service are safe and protected. A number of staff recruitment files were examined, and there was evidence that all the required employment checks have been undertaken prior to commencing work at the home. Evidence confirms all staff had a CRB check, where staff’s CRB’s are over three years old, the registered provider should consider renewing them. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The registered manager has a wealth of experience and knowledge and is able to demonstrate her ability to manage the home. She holds the required management and care qualifications, and operates an open door policy to ensure she is accessible to staff and people who use the service. People who live at the home and their relatives spoke highly of the manager and said she Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 21 was very caring. Staff and group meetings ensured that staff were informed about training opportunities and the day to day running of the home, they were also encouraged to be involved in decision making. Residents meetings are used to ensure they play an active part in making decisions about how the home is run. The manager consults with people on an individual basis to gain their views, and there was evidence that there is a quality assurance system, although the manager said the surveys had not yet been sent out for this year. People who use the service are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of peoples personal allowance records were examined and checked, the records were accurate and there were clear auditing procedures. Accident reports are analysed by the manager to ensure risk assessments are developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current, ensuring the safety of service users. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 22 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 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 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 23 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 2 Standard OP18 OP30 Regulation 18 18 Requirement Staff must received training on the protection of vulnerable adults. Staff must receive refresher training in health and safety, infection control, and food hygiene to ensure they retain the necessary competencies to undertake their role within the home Timescale for action 01/09/07 01/01/08 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 OP29 OP38 Good Practice Recommendations CRB checks should be renewed after 3 years Policies and procedures (missing person, restraint) should be regularly reviewed to ensure they reflect the up to date needs of the organisation. Wentworth Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hall DS0000003110.V329145.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!