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Inspection on 28/06/07 for Wey Valley House

Also see our care home review for Wey Valley House for more information

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The needs of prospective residents are fully assessed before they move into the home and are reassessed following any major change, such admission to hospital. Detailed care plans have been drawn up and provide staff with effective guidance to the care and support needs of residents. Residents are very well supported to maintain their independence and are actively encouraged to maintain their links with the local community.Residents` healthcare needs are well met and the home has an effective working relationship with local healthcare professionals. The home is very attractively decorated and furnished to a good standard to meet residents` needs. Improvements are planned to provide every resident with en-suite facilities to their bedrooms.

What has improved since the last inspection?

No requirements were made following the last inspection.

What the care home could do better:

An immediate requirement was made at the time of the inspection that the receipt of medication into the home must be recorded and records must be kept to enable an audit trail to be followed. It is recommended that a member of staff is specifically allocated to carry out activities, so that residents can be offered a wide range of meaningful activities, and to ensure social activities are not postponed or cancelled due to other pressures on care staff. The home`s policy regarding abuse must to be reviewed and revised to include reference to local authority multi-agency procedures and all appropriate actions. The manager and staff must receive training in Safeguarding Adults. An immediate requirement was made at the time of the inspection, that people must not be employed to work at the home until all the required documents and information have been obtained, including Criminal Record Bureau disclosures. Staff must receive training appropriate to the work they are to perform.

CARE HOMES FOR OLDER PEOPLE Wey Valley House Wey Valley House Mike Hawthorn Drive Farnham Surrey GU9 7UQ Lead Inspector Sandra Holland Unannounced Inspection 28th June 2007 10:30 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 Wey Valley House DS0000013827.V333104.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. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wey Valley House Address Wey Valley House Mike Hawthorn Drive Farnham Surrey GU9 7UQ 01252 712021 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) weyvalleyhous@ukonline,co.uk Abbeyfield Wey Valley Society Limited Mrs Shelley Tina Hartley Care Home 27 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (8) Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS Of the 27 (twenty-seven) older people (OP) accommodated, 6 (six) may be in the category of DE(E) and 8 (eight) in the category PD(E). 27th January 2006 Date of last inspection Brief Description of the Service: Wey Valley House is a large, purpose built property set in private grounds on the bank of river Wey. The home is in a quiet area of Farnham, within easy walking distance of the town centre. Wey Valley Society Ltd., operate the home and a sister home, which is very close by. The service provides 24-hour care for up to 27 older people. All bedrooms are used as single size and a number have en-suite facilities. It is planned to undertake further building work during Autumn 2007 to create additional ensuite facilities to rooms which do not currently have this. There is a large lounge, dining room and a number of smaller lounge areas leading onto balconies that look out onto the gardens. The service provides a range of activities and events for service users to attend, both in-house and within the local community. Car parking is available to the front of the property. The fees at this service range from £ 480.00 per week to £ 535.00 per week. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulatory Inspector carried out the inspection over seven hours. Mrs Shelley Hartley, Registered Manager was present representing the service. A full tour of the premises was carried out and a number of records and documents were sampled, including care plan, medication administration records and staff files. Ten residents, five members of staff and a visiting healthcare professional were spoken with. A pre-inspection questionnaire was supplied to the home, was completed and returned and information from the questionnaire will be referred to in this report. The pre-inspection questionnaire indicated that the home has equal opportunities and equality and diversity policies and procedures. It was noted from the records and information provided, that the residents and staff are almost all from a British background. CSCI feedback cards were supplied to the home for distribution to residents, relatives and visitors and healthcare professionals. Sixteen feedback cards were completed and returned by residents and nine were completed and returned by healthcare professionals. People living at the home prefer to be known as residents and that is the term that will used throughout this report. The inspector would like to thank the residents and staff for their hospitality, time and assistance. What the service does well: The needs of prospective residents are fully assessed before they move into the home and are reassessed following any major change, such admission to hospital. Detailed care plans have been drawn up and provide staff with effective guidance to the care and support needs of residents. Residents are very well supported to maintain their independence and are actively encouraged to maintain their links with the local community. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 6 Residents’ healthcare needs are well met and the home has an effective working relationship with local healthcare professionals. The home is very attractively decorated and furnished to a good standard to meet residents’ needs. Improvements are planned to provide every resident with en-suite facilities to their bedrooms. What has improved since the last inspection? What they could do better: An immediate requirement was made at the time of the inspection that the receipt of medication into the home must be recorded and records must be kept to enable an audit trail to be followed. It is recommended that a member of staff is specifically allocated to carry out activities, so that residents can be offered a wide range of meaningful activities, and to ensure social activities are not postponed or cancelled due to other pressures on care staff. The home’s policy regarding abuse must to be reviewed and revised to include reference to local authority multi-agency procedures and all appropriate actions. The manager and staff must receive training in Safeguarding Adults. An immediate requirement was made at the time of the inspection, that people must not be employed to work at the home until all the required documents and information have been obtained, including Criminal Record Bureau disclosures. Staff must receive training appropriate to the work they are to perform. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 7 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. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 8 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 Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents have been assessed before they were admitted to the home. EVIDENCE: The files of a number of residents were seen, including those of recently admitted residents. A detailed assessment of the needs of the prospective resident had been carried out by a senior member of the care staff team, to ensure that the home could meet those needs. The manager stated that a small number of residents are supported financially by a local authority. Where this was the case, an assessment had been carried out under the care management process and a copy of the assessment had been obtained. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 10 It was positive to note that a further assessment had been carried out following a resident’s admission to hospital, to ensure that any needs, which may have changed, could still be accommodated when the resident was discharged from hospital. The manager advised that intermediate care is not provided at the home. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Detailed care plans are available to guide staff to the care and support needs of residents and residents’ healthcare needs are well met. The administration of medication needs to be improved to safeguard residents. EVIDENCE: Comprehensive care plans have been drawn up detailing the care and support needs of each resident and it was positive to note that these had been signed by residents to show their involvement. The majority of the care plans had been written from the resident’s point of view and include how they liked to be assisted and their likes and dislikes more generally. A monthly review of the care plans had been carried out as recommended by the National Minimum Standards (NMS) for Older People, and this was recorded in the plans. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 12 Residents are supported to maintain their independence and a small number of residents administer their own medication. An assessment of the risks involved with this has been carried out and residents have signed these to acknowledge the risks and to indicate their consent. Assessments have been carried out of other risks to residents, including those of falling, of developing pressure sores and risks associated with the moving and handling of residents. Residents’ healthcare needs are clearly well met. A visiting healthcare professional advised that the home makes prompt and timely referrals when changes are noted in the health of residents. CSCI feedback cards were received from nine healthcare professionals and all responded positively, indicating an effective working relationship with the home. Records seen also indicated that a number of healthcare professionals are involved in the support of residents, including general practitioners, community nurses and hospital specialists. Medication is currently supplied to the home in “Nomad” trays, which are divided into separate compartments for medication to be administered at different times of day. Each compartment is sealed and contains all of the medications to be taken at specified times. Although the names and dose of the medications are stated on the trays, there is no way of knowing which medication is which, in the event of a resident wishing to omit a medication. It was also noted that the receipt of medication into the home had not been recorded, although there was a space allocated on the medication administration record (MAR) chart for this to be recorded. As a result, it was not possible to know how much medication should be present or to follow an audit trail. The manager stated that the home had already identified weaknesses in the current system and was planning to change the medication system to a monitored dosage system, where each medication is packaged and labelled individually. It was observed that the medication trolley was left unlocked and unattended, whilst staff administered medication to residents in the dining room. This is an unsafe practice, as medication may be removed by unauthorised people leading to misuse of the medication, and residents may not receive their medication as prescribed. Staff were observed to treat residents in a friendly, informal but appropriate and respectful manner. Residents’ privacy was promoted and staff were observed to knock on residents’ bedroom doors and wait for a response before entering. Assistance with personal care and mobility was offered sensitively and discreetly. Staff were observed to explain to residents, what was happening as they were being assisted. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 13 An immediate requirement was made at the time of the inspection, that the receipt of medication must be recorded and records must be maintained to enable an audit trail to be followed. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 14 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 and15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staff support residents to take part in activities and to maintain contact with their families and friends. A well-balanced diet is offered to residents and this is adapted if necessary to suit residents’ needs. EVIDENCE: A weekly plan of activities are offered to residents and this is displayed at the entrance to the dining room. The daily activities are printed on the menus which are placed on the dining room tables. Residents advised that the activities are enjoyable, but do not always take place as advertised and this can make it difficult for them to plan their other activities. A record of activities that have taken place is maintained and includes a record of which residents took part, to ensure that all residents have the opportunity to be involved. This was seen to include a variety of activities, such as an exercise class, birthday teas, basket ball, film shows, quizzes, walks by the river and themed events such as a “Wimbledon” tennis themed lunch. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 15 It was noted from the information supplied with the pre-inspection questionnaire, that no member of staff is employed with specific responsibility for activities. The manager stated that care staff usually arrange the activities and carry them out with residents. A committee of “Friends of Wey Valley Society” organise fundraising events for the home and fund entertainments and entertainers that are brought into the home. It is recommended that a member of staff is specifically allocated to carry out activities, to ensure that residents are offered a wide range of meaningful activities, and to ensure social activities are not postponed or cancelled due to other pressures on care staff. Residents are actively encouraged to maintain their links with their families, friends and the local community. Residents advised that visitors are made welcome in the home and a number of residents spoke of going for walks locally and into Farnham town centre for shopping. There are a number of communal seating areas in the home to enable residents to meet with their visitors. Staff advised that a small sitting room upstairs can also be used as a dining room for residents and their visitors. Staff advised that residents are encouraged to maintain their independence and make their own choices. It was positive to observe residents coming and going to their own activities in and out of the home, throughout the day. Most residents had brought their own belongings into the home to make their bedrooms more like “home”, including items of furniture, pictures, photo’s and ornaments. A two week menu was supplied with the pre-inspection questionnaire and from this it was noted that a well balanced and varied diet is offered to residents. A choice of main meals is available and staff ask residents each day what they would like for the next day’s meals. The majority of residents commented positively on the meals at the home, both to the inspector and through their CSCI feedback forms, advising that the food was good, portions were generous and meals were enjoyed. There were only occasional negative comments, including that the liver was tough on the day of inspection, and on a small number of feedback forms, more variety was requested. Meals are served in an attractive dining room, at tables laid with tablecloths, napkins and small pot plants. Aids to help residents maintain their independence when eating are provided, including non-slip mats and plate supports. Meals can be adapted to suit residents needs, and liquidised meals were observed for those residents who require them. Information in the preinspection questionnaire indicated that the home could provide meals to meet the needs of people from ethnic minority groups. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Only one formal complaint has been received and that was appropriately managed. More staff need to undertake training in Safeguarding Adults. EVIDENCE: The home’s complaints procedure is included in the Statement of Purpose, which is made available in the entrance hall. The manager advised that a separate copy of the procedure will be displayed so that it is more easily accessible to all who may wish to use it. Information in the pre-inspection questionnaire indicated that only one compliant had been received in the last year. The manager had responded to this in writing, to advise of the actions taken to address the issue raised. The manager stated that a complaints record is not maintained, as so few complaints are made, and that any dissatisfaction that is expressed is addressed immediately. No complainant has contacted CSCI with information concerning a complaint made to the home, since the last inspection. It was positive to note that the home has received a number of cards and letters of compliment and appreciation, including nine that have been received since January 2007. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 17 The manager stated that in the event of an allegation or suspicion of abuse, the home would follow the Surrey Multi-Agency procedure for Safeguarding Adults (formerly the Protection Of Vulnerable Adults). An up to date copy of the procedure is held in the home for staff to refer to if necessary. Other documents were also available to guide staff, including the Department of Health “No Secrets” policy and a “Manager’s Toolkit” regarding abuse, produced and supplied by Surrey County Council. The home’s policies and procedures were being reviewed and revised, the manager advised. The home’s policy on abuse was seen and was marked to show it had been reviewed in May 2007, but further review is necessary. It was noted that the abuse policy did not refer to the Surrey Multi-Agency procedure or other actions that should be taken if abuse was alleged or suspected. A record of staff training is maintained and from this it was noted that a number of care and ancilliary staff need to undertake training in the recognition and prevention of abuse. Ancilliary staff should receive abuse training as they have regular contact with residents and may have unsupervised contact with residents, their bedrooms and their belongings. The manager stated that she has not undertaken abuse training for a number of years. This must be updated so that the manager is aware of current policies and procedures and can adequately support her staff. Staff spoken with said they report any concerns to the manager or person in charge and staff were aware that any concerns could be addressed outside the home if required. These could be raised with the organisation’s general manager or chairman of the friend’s committee, both of whom make regular visits to the home. A requirement has been made regarding Standard 18, that all staff must receive training in Safeguarding Adults. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. The home is well furnished and equipped to meet residents’ needs and presents as a comfortable place to live. All areas were clean, freshly aired and appeared hygienic. EVIDENCE: Although the home was purpose built as a care home, the standard of the accommodation required by residents has increased, the manager advised. A small number of bedrooms already have an en-suite facility and all rooms have a wash-hand basin, but plans have been prepared to provide an en-suite toilet and basin to every resident bedroom. This is scheduled to take place later this year in three phases. A number of rooms have been left vacant to enable residents to move rooms within the home as each area undergoes building works. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 19 Residents are aware that this will be taking place and expressed some anxieties about the disruption, but acknowledged that their rooms should be improved as a result. The manager stated that the management team will be meeting with residents to discuss the issues causing concern to residents when the timescales for the building works are confirmed. The home was attractively and cheerfully decorated and furnished to meet residents needs in a homely style, with co-ordinating soft furnishings. The home was well maintained and presented as a comfortable place to live. Residents commented that they were happy with their rooms and it was positive to note that residents had made their rooms very personal with their own belongings. Information supplied in the pre-inspection questionnaire stated that improvements have been made to the furnishings and equipment in the home, including new furniture for the lounge, a new easy access bath and two new washing machines for the laundry. All areas of the home were seen to be clean, freshly aired and appeared hygienic. Paper towels and liquid soap were available in all appropriate places to maintain hygiene. Staff advised that personal protective equipment including gloves and aprons, are available and used as required to prevent infection and the spread of infection. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. A full team of staff are employed to meet the needs of residents. Recruitment of staff needs to be improved to fully safeguard residents. EVIDENCE: Information supplied with the pre-inspection questionnaire indicated that a full team of staff are employed to meet residents’ needs. The majority of the team are care staff, but catering and housekeeping staff also support residents. Maintenance in the home is carried out by an employee of the Wey Valley Society, who works across all the society’s properties. A number of care staff have achieved a National Vocational Qualification (NVQ) to Level 2 or higher and the home meets the recommended 50 of care staff trained to this level. It was positive to note that catering staff have also achieved NVQ qualifications. The manager stated that she is an NVQ assessor, as is the deputy manager and the organisation’s general manager. The recruitment files of a number of staff were sampled and it was noted that most, but not all of the required documents and information had been obtained before staff were employed to work at the home. For three staff, a Criminal Record Bureau (CRB) disclosure had not been obtained before they started working in the home and a check of the Protection Of Vulnerable Adults (POVA) Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 21 register had not been carried out. For another member of staff, their entitlement to work in the UK had expired and no record was held to show that this had been updated. The manager contacted this member of staff immediately and was advised that the entitlement to work in the UK had been extended and the document to confirm this was to be supplied to the manager the next day. These shortfalls are not in accord with the home’s policy on abuse which refers to vetting staff and to ensuring “that no person with a record of being an abuser will be employed”. Without carrying out a POVA check or a CRB, the home would not know if staff being employed had a record of abuse. A number of volunteers are involved with the home and carry out supportive roles such as fundraising and serving on the home’s management committee. The manager stated that checks on volunteers are carried out including CRB disclosures, although an up to date list of these was not available. The manager stated this would be requested from the chairman of the committee. Volunteers must not be permitted to have unsupervised access to residents or to take them away from the premises, unless a CRB disclosure has been obtained. Staff files included a number of records of training that had been undertaken, although not all. The manager stated that she was updating a training plan, to show all the training staff had undertaken and agreed to forward a copy of this to the inspector. The training plan was received before this report was written. From the training list, it was noted that a number of staff need to undertake training to enable them to carry out their role and to safeguard residents. Ancilliary staff need to receive training in the Control Of Substances Hazardous to Health (COSHH) as they are the main users of these products, and a number of staff need to receive training in first aid. As mentioned previously at Standard 18, further staff need to undertake training in Safeguarding Adults. An immediate requirement was made at the time of the inspection, that people must not be employed to work at the home unless the required documents and information have been obtained. A requirement has also been made regarding Standard 30, that staff must receive training appropriate to their role. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who has the knowledge and skills for the role, but the management needs to be more robust to fully protect residents. EVIDENCE: The manager stated that she has worked at the home for many years, has carried out a variety of roles and was deputy manager before being promoted to manager in 2000. Information supplied with the AQAA indicated that the manager has achieved NVQ Level 4 in care, the NVQ Registered Manager’s Award (RMA) and is an NVQ assessor. It was observed that the manager interacted with residents and staff in an informal and friendly way and was freely accessible to all. The manager Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 23 advised that she undertakes administrative duties in the home, as no administrative staff are employed. The weaknesses in the home’s medication and recruitment procedures which have been noted earlier, indicate that the home needs to be managed more robustly to ensure that residents are fully safeguarded and to ensure improved outcomes for residents. The Wey Valley Society, which operates the home, is run by a management committee and the chairman of the committee regularly visits the home, as does the organisation’s General Manager. Both the chairman and the general manager are accessible to residents and staff to discuss any issues that may arise. Visits to the home under Regulation 26, are carried out by members of the management committee or by the general manager. Regulation 26 requires organisations who are not in day to control of homes they operate, to appoint persons to visit the homes on their behalf. During these visits, the appointed person should speak to residents and staff, view the premises and write a short report of their findings and a copy of the report should be left in the home. The visits under Regulation 26, form part of the home’s quality assurance processes. The manager stated that two quality questionnaires are supplied to residents each year and the results of the questionnaires are reviewed and sent to residents by letter. Residents spoke appreciatively of the residents’ meetings they attend and other residents referred to these in their CSCI feedback forms. The meetings are valued as they provide residents with the opportunity to discuss and air their views about all aspects of the running of the home. Monies are not held for safekeeping on behalf of residents, the manager advised, as any expenditure made by the home on a resident’s behalf is invoiced to the resident or their representative. Information supplied in the pre-inspection questionnaire indicated that equipment and systems in the home are maintained and serviced to the required frequencies, to safeguard the health and safety of all who live and work in the home and no hazards were noted during the tour of the premises. An internal quality audit carried out last autumn, indicated that the fire alarm and temperature of the hot water supply both needed to be tested more regularly. The records for both of these were seen and it was noted that they are now being carried out to the required frequency. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13 (6) Requirement The manager and staff must receive training in Safeguarding Adults to prevent residents being harmed or suffering abuse, or being placed at risk of harm or abuse. Staff must receive training appropriate to the work they are to perform. Timescale for action 28/08/07 2 OP30 18 (1) (c) (i) 28/08/07 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 OP12 Good Practice Recommendations It is recommended that a member of staff is specifically allocated to carry out activities, to ensure that residents are offered a wide range of meaningful activities, and to ensure social activities are not postponed or cancelled due to other pressures on care staff. The home’s policy and procedure regarding abuse should be reviewed and revised, to refer to the local authority multi-agency procedure and to clearly specify all actions which should be taken if abuse of a resident is suspected DS0000013827.V333104.R01.S.doc Version 5.2 Page 26 2 OP18 Wey Valley House or alleged. Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Wey Valley House DS0000013827.V333104.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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