Inspection on 09/09/05 for Wetley Manor Residential Care Home Limited

This inspection was carried out on 9th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Wetley Manor Residential Care... 03/10/06

Wetley Manor Residential Care... 22/02/06

Wetley Manor Residential Care... 10/03/05

Wetley Manor Residential Care... 11/11/04

Wetley Manor Residential Care... 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Wetley Manor Residential Care Home Ltd Abbey Road Wetley Rocks Stoke-on-Trent Staffordshire ST9 0AS Lead Inspector Lynne Gammon Announced 9 September 2005 th 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. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wetley Manor Residential Care Home Limited Address Abbey Road Wetley Rocks Stoke-on-Trent Staffordshire ST9 0AS 01782 551144 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) Wetley Manor Residential Care Home LTD Mrs Dianne Barbara Rushton CRH 22 Category (ies) of MD(E) - 5 registration, with number OP - 22 of places PD - 2 PD(E) - 8 Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: PD - 2 Beds minimum age 55 years and over Date of last inspection 10th March 2005 Brief Description of the Service: Wetley Manor Residential Care Home is a care home providing personal care and accommodation for up to 22 residents. The home is dedicated to caring for elderly people who require residential care with a Mental Disorder, excluding learning disability or dementia (2), Old age, not falling within any other category (22), Physical disability (2), Physical disability over 65 years of age (8). The home is privately owned by Wetley Manor Care Homes Limited. The home is located in the rural village of Wetley Rocks, Staffordshire and is accessed from the road via a long driveway. Amenities can be reached by transport but are not within walking distance. The home is laid out on one level and has 20 single and one double bedroom all with en suite facilities. There are five communal rooms including a conservatory and sun lounge area, and a separate dining room. The grounds are spacious, attractive and accessible to residents. Views from the home are of the surrounding countryside. There is a car parking area at the entrance to the home. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 9th September 2005 at 09.30 a.m. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 7 hours. The registered provider, Mr Imran Shah for Wetley Manor Residential Care Home Limited, and the registered care manager, Mrs Dianne Rushton were present throughout the inspection. Also on duty were 2 care assistants, a cook and a domestic. The home also employs another cook, a gardener for a few hours a week and a general assistant who works part-time at the weekends only. Mr Shah takes responsibility for most of the redecorating and maintenance at the home. There were 22 residents living in the home at the time of the inspection and these staffing levels were satisfactory to meet their needs. The inspection included a tour of the building, inspection of records, observation, and discussions with residents, the registered provider and staff. Since the last inspection on 10th March 2005, no complaints nor any incidents or reports of abuse of any kind had been received. Two requirements against the regulations were outstanding from the last inspection report. All residents had received a pre-admission assessment and were invited to visit the home before making a decision to move there. A trial period of 6 weeks following admission enabled the individual to decide if the home was the right place for them. Care plans had been well written and health, personal and social care needs had been met and well documented. Residents confirmed that they were treated with dignity and respect and were very happy living in the home. The home was generally well maintained, homely, and very clean. Some redecorating and refurbishment had taken place since the last inspection and new items of furniture had been purchased. All of the bedrooms contained a range of personal items belonging to the individual resident and a good standard of furniture and fittings. The communal areas were bright, comfortable and warm. Food was well presented, varied and nutritious with choices available to meet a range of needs. Staff supervision had not taken place and this needed to be addressed. However, regular staff meetings enabled staff to contribute to service delivery and took place approximately every 4 months. There had been some staffing problems in terms of filling vacant posts but a good standard of service had Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 6 been maintained and the home was run in the best interests of the residents. Recruitment and selection procedures within the home needed to be more robust for the ongoing protection of the residents. Residents were able to make their own choices and decisions about the day-today activities within the home. What the service does well: 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. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 and 5 Pre-admission assessments were undertaken to identify individual needs and confirmation given that these needs could be met. Prospective residents and their relatives were able to undertake trial visits to enable them to make an informed choice about the home. EVIDENCE: The registered care manager confirmed that pre-admission assessments were carried out for all potential residents and inspection of records supported this providing details of personal care needs, medical history, religious needs etc. Residents confirmed that there were able to visit the home for a meal or to join in an activity before moving in and trial periods were offered for the first 6 weeks to give residents the opportunity to see if the home was suitable for them. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 and 10 The care planning processes were well documented and enabled staff to have a clear understanding of resident’s needs. All health care needs were met and residents were protected by robust medication policies and procedures. Residents were treated with dignity and respect. EVIDENCE: Individual plans of care were examined and it was clear that the health, personal and social care needs of the individual residents were being met very well. Each care plan contained a photograph of the resident, and were set out to include all aspects of daily living which were reviewed each week and signed and dated accordingly. Risk assessments were completed in detail and reviewed monthly. Records showed that residents had access to other health care specialists including the GP, district nurse, optician, dentist, chiropodist etc. The Medication Administration Records and medicine stock levels were examined and found to be accurate and authorised appropriately. Medicines were stored correctly in a safe and secure environment for the protection of the residents. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 10 Staff were observed knocking on bedroom and bathroom doors before entering and residents confirmed that they were treated politely and respectfully, and their privacy was upheld. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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, 14 and 15 There were a range of social, religious and recreational opportunities available to meet the expectations of the residents within the home. Family and friends were welcomed and residents were supported to maintain contact with them. Residents were encouraged to make their own choices and have control over their day to day lives. Dietary needs of residents were catered for very well to meet a variety of individual needs. EVIDENCE: The home’s activities co-ordinator post was vacant at the time of the inspection. However, the home had a variety of activities available for the residents which included: movement to music, entertainers such as a ventriloquist, singers, bingo, knitting, interactive gardening and the use of a greenhouse, garden fairs, outings to the theatre, hairdresser, celebrating key events such as VE Day, Easter, pub games, clothing parties etc. Religious needs were also catered for. During the inspection, residents confirmed that staff were very welcoming towards their relatives and friends. A number of completed questionnaires were sent directly to the Commission by residents and relatives and included the following comments from residents: ‘A very good home’, ‘I am comfortable at Wetley Manor Residential Home. I have been here for over 3 years which speaks for itself and I have no desire to move …’, ‘Especially well run home, I Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 12 am delighted to be here’. Comments from relatives included: ‘ I find that the home is very well run and very clean’, ‘My cousin has been in the home since Easter. At all times I feel he has been extremely well treated. They are all helpful and friendly. The food is wonderful’. One relative suggested that ‘a bit more entertainment would be good’. Residents told the inspector that they were very happy living in the home and confirmed their high levels of satisfaction with the staff including the owner, and the service provided in the home. Observation and discussion with residents evidenced that they were able to make their own choices in their day-to-day lives. Residents had been offered the choice of having a lock fitted to their bedroom door and having their own key following a suitable risk assessment. Care planning records identified those residents who had asked for this facility and the inspected noted that this had been put in place as required. The inspector examined the catering records in the kitchen and all temperature recordings and cleaning schedules were up-to-date. Menus were seen to be varied and well balanced. The cook provided a high standard of traditional home cooking and was very knowledgeable about the needs of the residents, and their likes and dislikes. The kitchen was very clean and well organised. Lunch was served during the inspection and appeared to be well presented and nutritious. Residents were seen to have wine or fruit juice with their lunch and were extremely complimentary about the food and the cook. The dining room was very clean and homely, and each table was laid with cloth napkins. There were ceiling fans in the dining room and an organ in the corner of the room, which was played by one of the residents on occasions. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 and 18 The home had a satisfactory complaints procedure and residents were listened to and their comments acted upon. Residents were protected from abuse. EVIDENCE: The Commission had received no formal complaints since the last inspection and none had been received by the home over the last 12 months. The complaints procedure was observed in the hallway of the home for the benefit of residents and visitors alike. Minor complaints were received by the registered care manager and resolved to the satisfaction of the residents. The home had an Adult Protection procedure which ensured the safety and protection of the residents. However, it is recommended that abuse awareness training be provided for staff to ensure the continued protection of all residents. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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, 20, 24 and 26. The location and layout of the home was suitable and safe to meet individual needs. Indoor and outdoor communal facilities were accessible, maintained to a high standard and clean, bright and comfortable. Resident’s bedrooms were homely, personalised and well maintained. The home was spotlessly clean throughout, which contributed to the overall control of infection. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 15 EVIDENCE: The home was located in a quiet, rural area surrounded by fields and was accessed from the road via a long driveway. Amenities could be reached by transport but were not within walking distance. There were gardens to the front and rear which were spacious, well maintained and accessible, providing seating facilities for the residents to sit and enjoy the outdoors. A car parking area was available at the entrance to the home. Indoor communal facilities included a lounge, dining room, sun lounge and conservatory. These were bright, homely and very clean. The conservatory contained new cane furniture and was a very pleasant room for residents to enjoy. A significant amount of redecorating had taken place in the home since the last inspection, which had been carried out to a high standard, and new carpets had been laid in certain areas. The furniture and fittings were of good quality, and contributed to an overall pleasant and relaxing ambience within the home. Individual bedrooms were decorated and maintained to a high standard. Each room contained a variety of personal items and furniture belonging to the individual resident. All had en-suite facilities and were clean, homely and bright. All radiators were guarded, adequate lighting and electrical sockets were in place and smoke detectors were fitted in each room. Telephone sockets and TV points were evident in each room. Residents were very complimentary about the home and their bedrooms. One resident told the inspector that ‘my room is just the way I like it, with all my things around me’. As stated, the home was exceptionally clean and free from malodour, and the domestic staff should be commended for the high standard of cleanliness maintained within the home. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 and 29 Staffing numbers and skill mix was appropriate to meet the assessed needs of the residents. Recruitment and selection procedures were in place but needed to be further strengthened to ensure the continued protection of the residents. EVIDENCE: Staff rotas were examined and showed that sufficient numbers of skilled staff were in place for the number of residents living in the home. However, some vacancies were in place, and the registered care manager was providing cover for a number of care staff hours. This was not an ideal situation and it was recognised that this situation could not continue indefinitely. Adverts had been placed to try to fill the vacancy and the staff were to be commended for maintaining a high standard of service for the residents during this time. Two staff files were examined and found to have some gaps in the required elements of Schedule 2 of the Care Standards Act 2000. For example, no photographs were on file for each staff member and in one file there were numerous proofs of identity, the other did not contain any. Both had Criminal Record Bureau clearances and details of training completed, plus Application Forms, Records of Interviews and Contracts of Employment. It is a requirement of this report that all elements of Schedule 2 are included within each staff file to ensure the protection of residents. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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) 32, 33 and 36. There was an open and positive atmosphere within the home for the benefit of the residents. The home regularly reviewed aspects of its performance which included seeking the views of residents and staff. However, formal supervision sessions for staff did not take place. EVIDENCE: As stated previously, the Commission received a significant number of completed questionnaires from both residents and relatives regarding the standard of care at Wetley Manor Residential Home. The comments within some of these, discussions with residents and staff and direct observation evidenced that the style of management within the home promoted an open and positive atmosphere which created a ‘home from home’ environment for those who lived there. Residents meetings took place every 4 months and minutes of these meetings were examined. The inspector noted that the residents contributed well in the Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 18 meetings and that their views were taken into account and used to influence the running of the home. Staff meetings took place every 4 months and minutes were seen as recorded. However, staff supervision sessions did not take place although the inspector was shown a new supervision form designed to be used for all staff. It is a requirement of this report that formal supervision sessions take place for all care staff at least 6 times per annum. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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 4 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 4 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 4 3 x x 2 x x Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 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. 2. Standard OP 29 OP36 Regulation 19 Sch 2 18 (2) Requirement Staff files to contain all elements as required in Schedule 2 for the ongoing protection of residents. Care staff to receive formal supervision at least 6 times per annum. Timescale for action Immediate and ongoing 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP 18 Good Practice Recommendations All staff to receive abuse awareness training. Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wetley Manor Residential Care Home Ltd E51-E09 S5033 Wetley Manor V241923 090905 Stage 4.doc Version 1.40 Page 22 - 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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