Inspection on 14/08/07 for Wentworth Lodge

This inspection was carried out on 14th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wentworth Lodge 20/07/06

Wentworth Lodge 10/11/05

Wentworth Lodge 24/01/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Wentworth Lodge Wentworth Road Bushbury Wolverhampton West Midlands WV10 8EH Lead Inspector Rosalind Dennis KEY Unannounced Inspection 14th August 2007 09:30 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 Lodge DS0000020877.V343291.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 Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wentworth Lodge Address Wentworth Road Bushbury Wolverhampton West Midlands WV10 8EH 01902 570208 01902 570208 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) Mrs Sandra Ann Dell Mrs Valerie Tanner Care Home 30 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (30) of places Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of person for whom residential accommodation with both board and personal care is provided at any one time shall not exceed 30 persons category I. That is females 60 years and above and males 65 years and above. 20th July 2006 Date of last inspection Brief Description of the Service: Wentworth Lodge is a care home providing accommodation and personal care for 30 older people. The home is located in the Bushbury area of Wolverhampton and is close to local shops and is easily accessible by public transport. Wentworth Lodge consists of a two- storey building with lift access between floors. All the bedrooms are single occupancy of which two have en-suite facilities. There are a variety of sitting/lounge and dining areas, which create a ‘homey atmosphere’. The gardens are well maintained and raised flower beds further enhance the outside space. The manager confirms that weekly fees for each individual are £347. Services such as chiropody and hairdressing incur additional cost. Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around 6 hours. All ‘key’ standards were assessed during the daythat is those areas of service delivery that are considered essential to the running of a care home. During the inspection time was spent speaking with people living at the home and their visitors, speaking with staff, as well as looking at records and observing staff in their work. Comments and views were collated from people living at the home, staff on duty and visitors, and the content of these is reflected within the individual outcome groups in the report. Some weeks prior to this inspection the manager had responded to a request by CSCI to complete an annual quality assessment document (AQAA)information within this document demonstrates that the manager is very much focussed on achieving good outcomes for people living at the home but also recognises where the home could improve and the steps needed to achieve those improvements to benefit people living at the home. The information contained within the AQAA also formed part of the inspection process The manager, Valerie Tanner was on duty for the duration of the inspection and the responsible individual, Sandra Dell attended for the purpose of feedback. The inspection found the home functioning well, people living at the home appeared content and eager to provide their views on how their needs are met at Wentworth Lodge. What the service does well: People living at the home are cared for by a staff group who are enthusiastic in ensuring people receive good care-frequent comments of ‘the staff are very good’ were made by visitors and people living at the home. Staff assess and plan care to take account of peoples’ likes/dislikes and preferences. Staff recognise diversity and cultural needs. The home has a committed staff group who communicate effectively with people and show kindness in their approaches. The service user guide describes Wentworth Lodge as a ‘home from home’ – comments received at this inspection show that this is an accurate reflection of the home. Observation of a selection of questionnaires recently received from relatives of people living at the home showed a high amount of satisfaction with all areas of the home and the care provided. Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 6 The manager is focused on positive outcomes for people living at the home and leads and supports a staff team who share the same values. The home continually monitors and reviews processes to ensure that people receive a good range of quality services. 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 Lodge DS0000020877.V343291.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 Lodge DS0000020877.V343291.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): 1, 2, 3 and 5. Quality in this outcome area is good. The home has a good assessment and admission procedure, which ensures that the home is able to meet people’s needs. The sources of information about the home need some updating to ensure people are provided with accurate information. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people recently admitted to Wentworth Lodge spoke of how they visited the home on several occasions prior to making the decision to stay, describing how staff helped them feel very welcome. Observation of care files shows that the manager conducts detailed assessments prior to and on admission to the home involving the individual and/or their significant other and this helps to ensure that the home is able to meet people’s needs. These assessments show that the home seeks detailed information about the individual’s care Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 9 needs and any other matters that are important to them, such as their significant others, hobbies, cultural and religious needs –observation of care plans shows that this information is then used to plan the person’s care. The home has a statement of purpose and service user guide, which are easy to read and readily available within the home, however both documents require some amendments to bring them up to date. All care files that were seen contained a ‘terms and conditions’ form, which had been signed by each person living at the home - it was discussed with the manager that people should be provided with a copy of the terms and conditions for their own personal reference. Wentworth Lodge DS0000020877.V343291.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 and 10. Quality in this outcome area is good. There is clear and consistent care planning in place, which focuses on the individual needs of people living at the home and provides staff with the information they require to meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Throughout the inspection staff were observed attending to peoples care needs promptly and with respect. Eight people living at the home who were spoken with during the inspection provided very positive comments on how they are cared for at Wentworth Lodge, comments included ‘staff are always caring’, ‘staff very helpful’, ‘everyone looks after me well’. People visiting the home also spoke of their satisfaction with how the home and staff group looks after people. Information that is obtained at the time of admission is used to plan how to meet people’s care needs, three care files were seen and this shows that staff plan and review care using an effective care planning and risk assessment Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 11 process. The home plans care according to individual wishes and preferences and provides staff with the information and guidance to meet care needs, for example information is included within care plans on how people like to look, their sleep pattern, whether they prefer a quilt or blanket, what time they like to get up/go to bed – discussions with people living at the home provided confirmation that staff follow the information provided in their care plan. Observation of care files shows that the home seeks advice from health and social care professionals and GP’s from a local practice regularly visit the home. The manager provided confirmation that staff involved in the administration of medication have received training and a staff member seen administering medication at the time of inspection appeared competent with this procedure. A selection of Medication Administration Record sheets that were observed had been completed accurately-although the manager was advised to seek clarification regarding the administration of one person’s medication. A room used to store medication was found disorganised –the manager acknowledged this and confirmed that a community pharmacist is due to visit the home within the next few days to assist with re-organisation. The home does not currently monitor the temperature of this room and is therefore advised to do this to ensure that medicines are stored at the correct temperature. Wentworth Lodge DS0000020877.V343291.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 and 15. Quality in this outcome area is good. The home provides a range of activities and the meals at the home are good, offering variety and catering for different nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home spoke of their satisfaction with the activities provided, describing how staff assist in the provision of board games, bingo and videos, and also that staff respect that some people prefer not take part in organised events. Information provided by the manager shows how the home has improved access to events in the wider community through the local ‘ring and ride’ service, enabling shopping trips and pub lunches to be undertaken. People also visit the home to provide musical entertainment and a church service is held monthly. The provision of larger print board games ensures that people with a visual impairment are able to join in with activities. The manager and staff acknowledged that written records designed to confirm when people have participated in activities need to be kept up to date. Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 13 One visitor to the home stated that each time she visits the home, staff are always friendly, polite and communicate promptly if any changes occur with their relatives condition. All people spoken with during the inspection confirmed that meals provided by the home are good, with a range of choices available to meet individual needs. People confirmed that they can choose whether to eat in their own rooms or in the dining areas and throughout the day staff were seen to provide prompt and sensitive assistance to people who needed help with their eating and drinking. The manager has recently sought information on providing meals for people of different ethnic backgrounds, enabling the home to ensure that special diets and people’s cultural dietary needs are met. Dietary preferences and any specific aids or assistance are clearly recorded within people’s care plans. Wentworth Lodge DS0000020877.V343291.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 and 18. Quality in this outcome area is good. The home has a complaints procedure that ensures that people’s concerns are listened to and acted upon and staff are provided with training to equip them with the knowledge to protect people from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people spoken with confirmed that they would feel comfortable in raising any concerns with either the manager or other staff at the home. The home has a complaints procedure on display in the reception area. A copy of the service user guide obtained at the time of inspection did not contain information on the complaints procedure and the home needs to ensure that this is included and a minor amendment made to the complaints procedure. Observation of the home’s complaints file shows that the home responds to any complaints robustly-one complaint has been received since the last inspection and this was responded to sensitively by the home and has resulted in changes to how the home records property and valuables. Minimal complaints have been received by the home since it was first registered and CSCI has not received any recent complaints regarding the home. Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 15 The manager confirmed that staff receive training in adult protection and abuse awareness and during a discussion staff spoke confidently about the importance of safeguarding people from the risk of abuse. It was established that the home does not have a copy of the recently updated local area adult protection policy and the manager was strongly recommended to obtain a copy of this procedure and make staff aware of its location Wentworth Lodge DS0000020877.V343291.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 and 26. Quality in this outcome area is good. The home is well maintained and provides a comfortable environment for people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of a selection of individual bedrooms found them decorated to a good standard, with photographs and pictures providing personal touches. People spoke of their satisfaction with their bedrooms and other areas of the home such as the communal lounges. Information provided by the manager prior to this inspection demonstrates that the home has an ongoing programme of redecoration. The manager and responsible individual spoke of their intention to enhance areas of the home through a process of Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 17 refurbishment-including the replacement of the carpets in two of the lounges, which is an outstanding requirement. All parts of the home were clean and hand-washing facilities are available for staff to use at the point of delivery of care, such as in people’s bedrooms – however it was brought to the attention of the manager that soap had not been provided in all toilets accessible by staff and people living at the home. People and visitors to the home described how the home is always kept clean and fresh smelling. The manager confirmed that the local infection control specialist had visited the home earlier in the year and was satisfied with hygiene practices-additional infection control training is planned for later in the year. Wentworth Lodge DS0000020877.V343291.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 and 30. Quality in this outcome area is good. The home is well staffed with adequate numbers and skill mix of staff, which ensures that sufficient staff are available to meet people’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home spoke of how they feel that staffing levels are consistently sufficient to meet their needs and observations made during the inspection confirmed that staff were able to attend to peoples requests promptly. Five members of care staff who were spoken with commented positively regarding training opportunities within the home and teamwork -in that everyone works well together and that enough staff are available to provide care. The manager provided information that 100 of care staff have either attained or are on a programme for NVQ 2 in care, which shows that staff are supported to obtain qualifications for their role and staff confirmed regular access to training. The home has devised its own induction programme for staff, which incorporates safe working practice topics and provides staff with information such as promoting cultural awareness and treating people with Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 19 respect. It was discussed that the home needs to ensure that this induction programme is based on the Skills for Care induction. Observation of two staff files demonstrated that all the required preemployment checks had been undertaken. Wentworth Lodge DS0000020877.V343291.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, 32, 33, 35, 36 and 38. Quality in this outcome area is good. The manager is focused on positive outcomes for people living at the home, leading and supporting a staff team who share the same values. The home is continually monitoring and reviewing processes to ensure that people receive a good range of quality services. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information available at this inspection demonstrates that staff and management at Wentworth Lodge are committed to ensuring that people consistently receive a good standard of care. The home is well managed by Valerie Tanner who is qualified in both practice and management and has considerable experience in caring for older people. Observations made, Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 21 discussions with people living at the home, their relatives and staff indicates that the Care Manager is very approachable and operates an ‘open door’ policy. For the purpose of this inspection the manager had responded to a request by CSCI to complete an annual quality assessment document (AQAA)-the information within this document demonstrates that the manager is very much focussed on achieving good outcomes for people living at the home but also recognising where the home could improve and the steps needed to achieve those improvements to benefit people living at the home. The home has various methods to monitor quality within the home, such as regular meetings are held with people living at the home, their relatives/significant others and the home regularly distributes questionnaires so as to receive feedback – results of the questionnaires are then collated and an action plan devised if necessary. Observation of a selection of questionnaires recently received from relatives of people living at the home showed a high amount of satisfaction with all areas of the home and the care provided. Staff feedback is also sought on how the service is managed and observation of completed staff surveys show that staff feel they are supported and confirm that the manager is accessible. The manager provided confirmation that staff are managed by a clear supervisory structure and regular meetings are held with staff to give instruction, guidance and direction. Staff spoke of how the home’s supervision and appraisal process is effective, enabling staff to reflect and improve on practice and identify training needs. Secure facilities are available for the safekeeping of peoples’ personal money and valuables, supported by written records of all transactions and regular audits are also undertaken. The home has provided information within the AQAA submitted to CSCI that servicing and maintenance of equipment is undertaken and equipment seen in use appeared well-maintained. It was established that the home does not have access to a hoist and that staff are currently physically lifting a person living at the home following a rapid deterioration in their condition-it was discussed with the manager that this is not safe practice and is putting the person and staff at risk of injury-the manager took action during the inspection to address this but the home is advised to consider access to a hoist to ensure that people who are unable to move independently are moved safely. Observation of staff training certificates show that staff have received training in the use of fire extinguishers but have not received additional training in evacuation techniques-the manager was advised to seek advice from the local fire officer regarding this training and in respect of suitable door closure devices for people living at the home as the manager reported that a small number of people living at the home prefer to have their door open at night. Wentworth Lodge DS0000020877.V343291.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 2 3 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 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 X 3 Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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. Standard Regulation Requirement Timescale for action 01/12/07 1. OP19 23 The registered person must ensure that the carpets on the first floor and lounge 3 and 4 are replaced. (14/08/07-Assessed as in progress, previous timescale 1/12/06) 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 OP1 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and amended. This will ensure that people admitted to the home are provided with up to date information on the services offered by the home. The temperature of the room used to store medication should be monitored and recorded. This is to ensure that medication is stored at the correct temperature. It is strongly recommended that the home obtain a copy of the new local area adult protection policy. This is to DS0000020877.V343291.R01.S.doc Version 5.2 Page 24 2 3 OP9 OP18 Wentworth Lodge 4 5 OP38 OP38 ensure that the manager and staff are kept informed of the processes to follow should any incident or allegation of abuse occur. The manager should ensure access to a hoist. This is to ensure that people are moved safely and staff protected from the risk of injury. The manager should seek advice from the local fire officer regarding evacuation training for staff and in respect of suitable door closure devices for those people who prefer to have their door open at night. Wentworth Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Lodge DS0000020877.V343291.R01.S.doc Version 5.2 Page 26 - 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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