Inspection on 22/09/09 for Wentworth View

This inspection was carried out on 22nd September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wentworth View 09/09/08

Wentworth View 14/09/06

Wentworth View 16/02/06

Wentworth View 11/10/05

Wentworth View 11/01/05

Wentworth View 29/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Wentworth View 15 Brampton Road Wath Upon Dearne Rotherham South Yorkshire S63 6AN Lead Inspector Sarah Powell Key Unannounced Inspection 22nd September 2009 09:00 Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Wentworth View Address 15 Brampton Road Wath Upon Dearne Rotherham South Yorkshire S63 6AN 01709 871116 NONE wentworth.view@craegmoor.co.uk www.craegmoor.co.uk Sapphire Care Services Limited 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) Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: 2. Learning Disability , Code LD The maximum number of service users who can be accommodated is: 4 9th September 2008 Date of last inspection Brief Description of the Service: Wentworth View is a care home for younger adults with a learning disability. The home is registered for four people. The home is situated in a large village close to Rotherham. There are local facilities including shops and churches. It is a detached house with a comfortable and homely feel; there is a kitchen dining room, a large lounge and a conservatory. Four single bedrooms two with en-suite facilities and a communal bathroom. The garden is small but well maintained and meets people’s needs. The fees at Wentworth View at the time of this report September 2009 range from £1698.44 - £1727.50 per week. Additional charges are made for chiropody, hairdressing some activities and outings. The home has a copy of the latest inspection report, the Statement of Purpose and Service Users Guide. These were available. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We went to the home without telling them that we were going to visit. This report follows the visit that took place on Tuesday 22nd September 2009. The visit lasted from 9:45 until 14:45. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The purpose of the visit was to make sure that the home was operating and being managed in the best interests of people living there. Information has been used from different sources for this report. These sources includeReviewing information that has been received about the home since the last inspection. The annual quality assurance assessment. The acting manager had completed an annual quality assurance assessment (AQAA). The AQAA focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. The AQAA did not give us detailed information and did not reflect what was happening at Wentworth view. Notifications (Regulation 37) relating to incidents in the home affecting people using the service. Details of complaints and allegations raised by people connected to the service. At the site visit one inspector spent 5.0 hours at the home. During this time observation of interactions between staff and residents and care practices which took place. People using the service were observed and spoken with some relatives were contacted after the visit. Discussions with the acting manager regarding meeting needs, staffing, complaints, medication, mealtimes, protecting people and the environment took place. We spent time inspecting care plans, medication records, staff rotas, looking at individual rooms and reviewing a selection of health and safety information. Staffing and management issues were discussed and feedback was given to the acting manager at the end of the inspection. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The plans of care were poorly organised, difficult to find information and many things were duplicated; it was difficult to determine people’s needs and how to meet those needs. Peoples risks had not all been identified and risk management was not clearly documented to ensure people were safe. Staffing was not meeting people’s needs, many staff had left and remaining staff were working extra hours. Staff told us they felt like they were living at the home at the moment as they were covering so many shifts. Lack of staff was impacting on the daily activities, Wentworth views service user guide said it promoted activities and developed activity plans for each client, taking into account peoples wishes and abilities, yet activity plans were not available and depending on staffing numbers people did not go on activities but stayed in the home. This did not meet people’s needs. Some staff training required updating and first aid training needed addressing as only one member of staff had first aid training and that expired in December 2009. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs and aspirations were not assessed. EVIDENCE: The three people living at Wentworth view had lived there a number of years, the assessments carried out at time they were admitted were not available. We saw one dated 2005 in one plan of care; however it was not fully completed. There was also no assessment or review documentation carried out by social workers or reviewing officers, available on people’s files. The acting manager told us she had not seen any information from social workers, it was possible that it was archived but nothing was available in the working files. It was therefore not possible to determine if all people’s needs were identified or met. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 10 The AQAA stated, ‘All people have pre admission assessments and evaluation completed prior to admission with interested professionals, this forms the basis on initial care plan’. However there was no assessment carried out by the home for the people and no recent care management assessment or review, so it was very difficult to generate a plan of care as no needs had been identified in an assessment that was available. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans did not clearly identify peoples needs or have clearly identified measures in place to determine how needs could be met. EVIDENCE: The care plans were disorganised difficult to find information and not clear if needs had all been identified. A person centred format had been developed, however it was very generalised and covered a number of needs under one heading, gave very brief details on how to meet the needs so did not clearly set out the care required to meet the needs. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 12 Additional care plans had been inserted with the person centred plans, intending to cover other needs identified, however these were risks not care needs and should have been recorded as risk assessments with appropriate risk management arrangements documented to ensure people were able to take risks as part of an independent lifestyle. The person centred plans did not include people’s wishes or give staff an understanding of their capabilities if they were able to make informed decisions and choices. The plans did not set out how the home will meet people’s current and changing needs and aspirations or how people’s goals would be achieved. They were not written as personalised plans. The acting manager told us that she was well aware the plans required rewriting but the staff including herself had not received specific training on completing person centred plans. Rotherham contracts officers had suggested a course on person centred planning organised by Rotherham Council for the acting manager and staff to attend to ensure they were completed appropriately. The acting manager and staff also told us that due to staffing problems the time to develop new plans was limited; shifts had to be covered to ensure the appropriate staffing levels were maintained to safeguard people. Peoples changing needs were reviewed and professional advice and referrals obtained, however the advice given was not documented in care plans or risk assessments for staff to understand and follow, therefore putting people at potential risk of harm One person had been identified as at risk of choking, had been seen by a speech and language therapist who had clearly documented management of the risk in a letter, this letter was found in the care plan amongst other information, however no care plan or risk assessment had been drawn up by the staff to ensure that persons needs were met and the risk managed. The acting manager told us that another person had seen the speech and language therapist and had been identified as requiring their drinks thickened, however this was not documented anywhere in the care plan, with a number of new staff and staff from other homes covering shifts it is putting this person at potential risk. People were helped to make decisions however when staffing was low it was not always possible to enable the people to do what they had wanted. One person liked getting out regularly but on occasions over the last few weeks had been restricted with this, as not enough staff had been on duty. The staff were working very hard and covering extra shift and where possible were respecting peoples choices. Staff told us they realised peoples choices Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 13 were not always being carried out and this frustrated them as they could see it was affecting the peoples well being. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were not always able to access the local community or take part in activities as often as they wished. A healthy diet was offered. EVIDENCE: Wentworth view has always been an activity focused home enabling people to access the local community when they wished and take part in valued and fulfilling activities of their choice. However due to the staffing problems this at present was not always able to happen, as there was not always enough experienced staff on duty. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 15 The acting manager told us last week activities had mostly gone ahead as planned but this week was looking unlikely she said, “It is hit and miss at the moment”. Most shifts the week commencing Monday 21 September were requiring cover from staff who work at other homes so do not know the people and therefore not clear how to meet their needs while participating in activities in the community, which would be on a 1 to 1 basis and could potentially put people at risk. Rotherham contract officers had visited the home on 16 July 2009 and provided us with a copy of the information sent to the acting manager. They had requested that activity plans were developed as part of person centred care, taking into account peoples likes, dislikes and choices. At the time of our visit, this had still not been carried out. The acting manager told us she had been on annual leave had staffing problems so was working many shift rather than having office time and had not been able to completed the task. She was aware it required completing to ensure peoples recreational needs were identified and met. Staff supported the people to have relationships with family and friends; all the people had regular contact with family. Staff we spoke to were aware that relationships had to be appropriate to protect people. As they were not always able to make informed decisions, due to their learning disabilities. All people had a holiday earlier in the year, some had had caravan holidays and other had booked a cottage, the staff told us that the people had thoroughly enjoyed the holidays and were hoping to get away again, if staffing numbers increased. People were offered a healthy diet they often did the shopping with a support worker and helped prepare meals. Records were seen of food prepared and served the diet was varied and healthy eating was promoted. Staff said all people enjoy their meals and mealtimes. The people will also eat out, particularly if they are doing an activity, although this has been restricted over last few weeks, however from records it was evident that there had been takeaways brought into the home instead, as people enjoyed this. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive support in the way they prefer but not always when they prefer. Medication procedures to protect people are in place. EVIDENCE: People who live at Wentworth View were able to maintain their own personal care with support from the staff; People were also able within their capabilities, to choose their own clothes and hairstyles to reflect their personality. Staff we observed provided sensitive and flexible personal support and peoples privacy and dignity was maintained. However one member of staff on duty was working under supervision, as they were a new starter so could not give personal care. Therefore if people needed personal care at the same time one would have to wait which would not meet their needs. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 17 Staff told us they were struggling to do everything required with the staffing shortfalls, as three staff had left and one was on long term sick leave. The acting manager told us peoples healthcare needs were met, professional advice and referrals were made when required, however this was not clearly documented in care plans. We saw a letter from a speech and language therapist giving advice to be followed, but no care plan or risk assessment had been drawn up for staff to follow putting people at potential risk. We looked at medication administration records these were clearly signed when medication was given; protocols were in with records to ensure staff understood medication policies and procedures. Receipt of medication was well documented and returns were documented and accounted for. There had been one medication error, when a tablet had been found missing the acting manger had carried out a full investigation and all staff had redone competency assessments. However the acting manger had not considered that the medication could have been given to the person as an extra dose, it had been assumed it had been lost so the GP was not contacted for advice to ensure the person was safeguarded. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a good complaints procedure and safeguarding policy however people were not always protected due to staff shortages. EVIDENCE: There was a clear and effective complaints procedure, which included set timescales. The complaints procedure did not have up to date contact details for the CQC, or the correct address and telephone number, the acting manger told us she would rectify that to ensure people knew who to contact. The complaints procedure was also in an easy read format to enable people with a learning disability to understand. Two complaints had been received regarding staffing levels. Following one complaint a social worker had been allocated to review one person to determine if his needs were still being met at Wentworth view. Contracts officers from Rotherham council had also received information regarding inadequate staffing, and had requested an action plan from the acting manager to ensure people’s needs were met. The home has a good safeguarding policy, which clearly defined different types of abuse, and staff we spoke to were aware of different types of abuse and Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 19 they also told us about the importance of whistle blowing to ensure people were protected. However staffing levels and inexperienced staff could potentially put people at risk of harm. Rotherham contracts had received information regarding staffing levels from a whistleblower, who felt people were at risk because staffing levels were not always being maintained at the required 1 to 1. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using 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. Standard of cleanliness and environmental standards were good providing a homely, comfortable environment for the people that lived there. EVIDENCE: The standard of cleanliness throughout the home was good and all routine maintenance was carried out. Regular environmental audits were carried out and items requiring repair identified and rectified this ensured people lived in a well maintained environment. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 21 We identified some areas that required remedial work during our visit, the acting manager showed us a requisition to the company’s maintenance department, this showed the items had already been identified and were in the process of being remedied ensuring a safe environment. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were not always supported by competent staff, recruitment procedures were not always robust, and there was not an effective staff team. Some staff training was required to ensure staff were appropriately trained to meet peoples needs. EVIDENCE: The people who live at Wentworth view have one to one staffing, there should be eight staff employed to be able to deliver this level of support. There were only three staff and the acting manager on the rota, three staff had left and one was on long term sick leave. At the time of our visit there was an experienced senior, the acting manager and a new starter on shift. The acting manager had arranged to interview two applicants during the day and the new starter had not completed all the Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 23 recruitment checks so was under supervision and could not deliver personal care to people. This meant no activities outside the home were able to take place and the senior had to do all personal care. This staffing mix did not meet people’s needs. The new starter had also not received any induction training, was reading policies and procedures during our visit and had not received appropriate training to meet people’s needs. The acting manager told us she was using staff from other homes within the company to cover the shortfalls on shifts, existing staff were working extra shifts and she was working shifts. This was required in order to ensure people were safeguarded. We looked at staff files to determine recruitment procedures were robust, applications and references were seen and appropriate checks. However people were starting without full checks, which are acceptable but need to be formally supervised during this period; however with staffing numbers this was not possible. A number of references seen only detailed people’s employment dates no other information, further references should be obtained i.e. character references to be able to help decide people are suitable for the job applied for. We also looked at staff training files most training was up to date for the three permanent staff, however fire training needed updating, the acting manager told me this was booked. Only one member of staff had 1st aid training and this expired on 6/12/09. Staff should be first aid trained to ensure they can meet people’s needs, staff do activities outside the home on a one to one basis with people, therefore all staff should receive first aid training so people are safeguarded. Two of the three staff had NVQ qualifications and the third was doing NVQ level 2 to ensure staff were competent to meet peoples needs. The staffing rotas for weeks commencing 21/9/09 and 28/9/09 did not show adequate staff on duty, during our visit the acting manager covered shifts for the week 21/9 by using staff from another home, but still had to cover the following week to ensure people’s needs were met. At night a sleeping member of staff is on duty, this will be changed to a waking night when four people live at the home. However the acting manager told us that one person’s needs had changed and they got up on some occasions during the night. The sleeping staff did not always wake immediately so they had provided a lock on the kitchen door to ensure the person can not access the kitchen for their safety. This could restrict others access so the acting manager was going to put a protocol in place and risk assessment, the persons needs should be reviewed to determine that a sleeping staff can meet their needs. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 24 Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were good quality monitoring systems in place however they have not all been implemented recently. Health and safety procedures were in place. EVIDENCE: The acting manager commenced employment on 30/3/09 and is going through the registration process with CQC. She has previously worked as a senior support worker and team leader and has had over twenty years working in a care setting. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 26 The acting manger is working hard to try to resolve the staffing problems, which are having an impact on all quality outcomes for people living in the home and affecting peoples well being. Due to the staffing shortfall she is struggling to meet the requirements of the standards which mean people’s needs are not always met. The acting manager had completed an annual quality assurance assessment (AQAA). The AQAA focuses on how well outcomes are being met for the people using the service. The AQAA did not give us detailed information and did not reflect what was happening at Wentworth view. The company have good quality monitoring systems in place, however not all were being implemented at present. The monitoring systems that seek the view of the people and their relatives have not been undertaken since the acting manager started, this does not give people the opportunity to share their views. The acting manger told us all maintenance records were up to date, we looked at some and they were satisfactory. The acting manager told us the portable appliance testing had been carried out but were awaiting certificate. This ensured people lived in a safe environment. Staff did not have appropriate training in first; there was not a qualified first aider on duty at all times, which did not meet people’s needs. Staff were also waiting for updates in fire safety training, the home had a fire in May 2009 therefore the acting manager was more aware of the importance of fire training, yet only one member of staff had current fire training this could people at potential risk. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 1 3 x 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 1 X Version 5.3 Page 28 Wentworth View DS0000003138.V377754.R01.S.doc No 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 YA2 Regulation 14 Requirement People’s assessment of needs must be completed and kept under review in order that their needs are identified and met. All people must have a plan of care drawn up in respect of their health and welfare and how their needs will be met. Ensure the risks to people’s health and safety are identified and so far as possible eliminated to protect people. Make arrangements for people to engage in appropriate social activities, consult with people to develop a programme of activities to ensure their social needs are met. People’s health and welfare must be assessed and procedures in place to address them to ensure their needs are met. The numbers of staff on duty and their competence must be reviewed to ensure that the needs of people are met. Provide staff with appropriate training so that staff collectively has the skills to deliver the care, which the home provides. DS0000003138.V377754.R01.S.doc Timescale for action 01/11/09 2. YA6 15 01/12/09 3. YA9 13 01/12/09 4. YA12 16 01/12/09 5. YA19 12 01/12/09 6. YA33 18 01/11/09 7. YA35 18 01/12/09 Wentworth View Version 5.3 Page 29 8. YA39 24 All Quality monitoring systems must be maintained to ensure the home is run in the best interests of the people. 01/12/09 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. 3. 4. 5. 6. Refer to Standard YA7 YA13 YA16 YA18 YA20 YA34 Good Practice Recommendations Enable people to make decisions about their lives and given support as required to ensure their choices are respected. To enable people to access the local community to ensure peoples needs are met. The routines of the home should promote independence; choice and freedom of movement ensuring peoples needs are met. Staff should provide personal support in the way people prefer. Any medication errors should be reported to the persons GP for advice to ensure people are protected. The recruitment procedure should be followed, all checks should be completed before employment, character references obtained, which give more detail that just dates of employment and if employed on a PoVA first check the person should be supervised, this ensures people are safeguarded. Wentworth View DS0000003138.V377754.R01.S.doc Version 5.3 Page 30 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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