CARE HOMES FOR OLDER PEOPLE
WENTWORTH HALL Church Drive Wentworth Rotherham S62 7TW Lead Inspector
Valerie Hoyle Unannounced 23 June 2005 09:00. 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 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 CS0000003110.V204078.R01.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Wentworth Hall Address Church Drive Wentworth Rotherham S62 7TW 01226 748618 01226 748618 None Mr Paul Wilson Crabtree, Mrs. Gloria Crabtree Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Lisa Carpenter PC Care Home only 23 Category(ies) of OP Old Age 23 registration, with number of places WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 25 October 2004 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. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours where a partial tour of the buildings was undertaken. The inspector examined four service users care plans and supporting documentation. Eight service users and four staff were spoken to during the visit. The inspector was able to speak to one relative, and the hairdresser, to gain their views on how the home is run. What the service does well: What has improved since the last inspection?
The registered providers continue to make improvement to the fabrics and furnishings at the home. A new lounge carpet has enhanced the area for service users to spend their time, and new floorings have been fitted in a number of bedrooms as required from the previous inspection. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 6 The staff at the home continues to improve the methods for gaining the views of service users with quality assurance surveys and meetings. Service users have provided ideas for future entertainment and outings as well as suggestions to the food menus. Staff training and supervision has improved since the previous inspection, and the commitment of staff and the registered manager is commended. 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. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 5. Service users are not admitted into the home without a full needs assessment undertaken by the registered manager, to ensure their needs are met. Service users can visit the home prior to their admission to assess if they want to live there. EVIDENCE: The placing authority provides information to the home prior to admission and the registered manager is able to make an initial judgement about the suitability of the service user, and assess if the staff are able to meet their care needs. Information is gained from relatives and health professionals if the service user is admitted from outside the area to ensure their needs can be met at the home. Four assessment documents examined included sufficient information to ensure care needs can be met by the staff at the home. One service user was able to confirm that she/he was visited prior to admission, and said the staff were very good and were able to meet her/his needs. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9, 10. The care planning systems are sufficiently detailed to enable staff to deliver the care to service users who have specific identified needs. Arrangements for dealing with service users health issues are adequately met by staff at the home, with support from health professionals. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring their safety and protection. Staff have the necessary skills and knowledge to ensure service users are treated with respect and dignity. EVIDENCE: Five care plans examined and these were comprehensively written with clear methods of staff intervention. There is sufficient evidence to confirm staff on a regular basis reviews the care plans and comprehensive risk assessments ensure service users can maintain their independence while remaining in a safe environment. Staff are comfortable with their abilities to meet the needs of service users and they are well informed and trained to deliver the care. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 10 Records examined and discussion with the staff confirmed service users healthcare needs are met. District nurses give advice and support staff to ensures service users healthcare needs are met. Service users are escorted to medical appointments by staff and comprehensive records are completed ensuring information is shared with those who care for the individual. An audit of medication stocks and records was examined and were found to be correct ensuring the health and safety of service users. All senior carers have undertaken accredited medication training to ensure they have the required skills and knowledge. Comprehensive contracts are developed to enable service users to make decisions on self-medicating ensuring their safety and protection. There were many examples of good practise by staff and on many occasions there were good interactions between staff and service users and the visiting relatives. Most service users were referred to by their first name and this was with the approval of users, and was also stated in their care plan. One service users said that his/her live has changed for the better by moving into the home and he/she said the staff were wonderful. He/she said staff made him/her feel safe while being able to maintain his/her independence. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 11 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 standard(s) 12, 13, 15. Social activities are arranged by the home and service users are able to participate if they wish, to enhance their lifestyle experience. Mealtimes are well managed and the facilities promote a calm environment with a pleasant dining area to accommodate all service users. The home has clear visiting policies and procedures to ensure service users can maintain contact with their family and friends. EVIDENCE: There is a lively atmosphere at the home and service users choose where and with whom they want to spend their time. Service users spoke about the variety of entertainment provided by the staff and outside entertainers. One service user spoke particularly about a lady who had played a harp and said she/he had really enjoyed the beautiful music. Service users are aware of future events at the home and were able to describe the daily activities. One service user with a particular interest in gardening was able to show of his green house where he/she was growing tomatoes. He/she told the inspector that he/she did not realise how lonely at home he/she had become until he/she was able have all the company at Wentworth hall. He/she said it had changed his/her life. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 12 A visiting relative said he was always made to feel welcome and staff were very caring. The staff at the home encourage relatives to play an active part in the home and they are invited to social events and outings. The menus are well balanced with a good choice for each meal. Mealtimes were observed and the food looked good quality and was well presented. Staff were available throughout the meal and were able to give assistance where needed, they appeared to be unhurried and had time to chat to service users. Service users said the meals were very nice with a good variety and a number of service users said they liked to have their breakfast in their bedrooms so they could take their time getting up in the morning. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 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 standard(s) 16, 18. Service users and their relatives are provided information to enable them the raise concerns about the home and their care. Adult protection Policies, procedures and training of staff ensures the protection of service users from abuse. EVIDENCE: There is a complaints procedure that is available to service users 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. There is a comprehensive Adult Abuse and Whistleblowing 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 of abuse. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 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 standard(s) 19, 26. The registered provider continues to improve the décor and furnishings at the home creating comfortable and safe environments for service users. The home is clean and free from odours and there is sufficient domestic staff to maintain good hygiene standards. EVIDENCE: The registered providers continue to make improvement to the fabrics and furnishings at the home. A new lounge carpet has enhanced the area for service users to spend their time, and new floorings have been fitted in a number of bedrooms as required from the previous inspection. The home is situated along the driveway that leads to the local Church and is in a quite rural setting. Trees surround the gardens and there is an 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. Service users enjoy spending time in the garden and one service user has spent time planting flowers and tidying around the edges of the garden.
WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 15 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. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff rotas examined demonstrated there is sufficient staff to meet the needs of service users. Training in a number of areas has been undertaken since the last inspection; meeting all the outstanding requirements from previous reports. Staff continues to work towards attaining NVQ qualification although they do not meet the requirement of 50 NVQ qualified staff. The registered manager is hoping that most staff will obtain the qualification by the end of the year. A number of staff recruitment files were examined, and there is evidence that all the required employment checks have been undertaken prior to commencing work at the home, ensuring the safety and protection of service users. WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 38 The registered manager is skilled and experienced to manage the home to ensure the safety and protection of the service users. Procedures are in place to ensure the financial interests of service users are safeguarded. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment. The registered manager is able to demonstrate that they actively seek the views of service users. Staff are provided with formal supervision required to ensure they have the opportunities to develop new skills and knowledge. 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
WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 18 ensure she is accessible to staff and service users. Service users spoke highly of the manager and said she was very caring. Staff receives supervision and the manager undertakes all yearly appraisals, to ensure staff have to opportunity to discuss their development. A quality assurance survey is undertaken by the home every twelve months to gather the views of service users, staff and relatives. The registered manager is to focus attention to improve opportunities fro service users to go on outings. These are currently being arranged, based on venues suggested by service users. Service users are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of service users pocket monies were checked and these were accurate to audited records. 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 CS0000003110.V204078.R01.doc Version 1.30 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 3 x 3 WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations The responsible individual must work towards providing a minimum of 50 of staff who are NVQ level 2 qualified in 2005 WENTWORTH HALL CS0000003110.V204078.R01.doc Version 1.30 Page 21 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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