Inspection on 18/08/05 for Wings

This inspection was carried out on 18th August 2005.

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.

Other inspections for this house

Wings 01/02/07

Wings 06/04/06

Wings 23/11/05

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Wings 17 The Grove Beck Row Mildenhall IP28 8DP Lead Inspector Mike Usher Announced 18 August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wings Address 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP 01638 583934 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) Compass Care Ltd Mrs Joy Bentley Care Home 6 Category(ies) of MD Mental Disorder (6) registration, with number LD Learning Disability (6) of places Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/03/05 Brief Description of the Service: Wings is registered as a Care Home for 6 younger people with learning disability and/or mental health needs, and offers placements to individuals with challenging behaviour. The home is situated on a private road in Beck Row, near to Mildenhall air base. The location is semi-rural and transport is provided by the homes three vehicles to access local facilities. Parking is available at the front of the building. The bungalow offers six individual bedrooms. At one end the building there is a living room, while at the other end the dining room has recently had a dividing wall erected to provide a private and quiet area for service users and staff. The Manager’s office is situated at the front of the home next to a garage. The fenced garden is mainly grass, but has a patio area and vegetable/flower patch maintained by people living in the home. Wings is owned and run by Compass Care. Joy Bentley is the registered care manager. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection focused on progress regarding previous requirements and recommendations, significant developments, management issues, and the views of service users and staff. The inspection used observation, examination of records and other documents, discussions with management, staff, and residents, and made use of information provided by the home prior to the inspection visit. The registration of the home has undergone significant changes in recent months, with the original partnership converting to a limited company, which has in turn been acquired by the Tracscare Group. This has led to an increased investment in the home, mainly in the accommodation and staff training. The home has now achieved a very high level of compliance with the National Minimum Standards, with only one minor shortfall noted during this inspection, and the management and staff are to be congratulated on providing such a high standard of service. What the service does well: What has improved since the last inspection? The new owners have provided more specialist training for staff to enable them to better meet the more challenging needs of individual service users. Work is continuing to maintain and improve the accommodation. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 6 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. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 5 A new assessment process is being developed under the new owners, and service users are given a suitable document setting out the terms and conditions of the home, in an appropriate format. EVIDENCE: The Statement of Purpose has been revised to incorporate the recent changes in ownership. Copies of service users’ contracts were seen during the inspection. These were in a suitable format, using pictorial aids, and were signed by the service user. With the home about to experience its first change to the service user group for some time, it was possible to discuss the assessment process with the manager. She explained that the company was not rushing to fill the vacancy, and that an assessment involving the Regional Director (who is the Responsible Individual, and is experienced in this area) will take place to ensure that the choice made is suitable to the home’s needs (i.e. the current group of service users), as well as the individual. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 - 10 The service is well set up to meet service users’ needs and individual choices. EVIDENCE: The risk assessment process was discussed in detail with the manager, and appropriate consultation with other professionals was seen to form an important part of that process, including social workers, psychiatrists, and dieticians, as well as consultation with the service user. There is a good relationship with the local GP surgery, where the specific requirements of some residents has enabled this service to be adapted to their individual needs in a very positive manner. Risk assessments are detailed and textural (i.e. rationalised rather than using a scoring or tick-box approach), and there are detailed notes of formal reviews. The manager spoke positively about the expertise now available to her within the new parent company, and one of the Directors has already visited the home to discuss and advise on risk assessment and training. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 10 Care plans contain a good amount of details with information being usefully arranged and accessible. They are written in positive language and the setting of goals is also very positive. There is good evidence of service user involvement such as parts being written in the first person, and signed by the resident to confirm agreement. Activity plans are in place and needs are well documented, and includes different ways by which those needs can be met. These plans are reviewed ion a monthly basis. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 - 17 The home enables service users to pursue appropriate activities and participate in the local community. EVIDENCE: One of the service users spoken with during the inspection has space in the garage where they are able to work on maintaining their bicycle, and had recently passed their Cycling Proficiency Test. Another resident was due to take the test in the near future. Service users are involved in a variety of appropriate activities that enable them to participate in the local community and enjoy a range of leisure opportunities. This was confirmed in discussion with service users, and by reference to the care plans of service users which include an plan of activities that is devised and drawn up in consultation with individuals. The range of activities service users are involved in includes: - Supported Work Placements - Educational Courses Wings - Music - Gardening Version 1.40 Page 12 I54 - I04 S63585 Wings V255547 050818 Stage 4.doc - Sports Cinema Clubs Outings - Animal Care Cooking Swimming Day Care The home has 3 vehicles that are available for use depending on staffing levels. This facility provides a good level of flexibility in assisting service users to participate in the local community, and this was evident from the activity on the day of the inspection with many comings and goings for various reasons. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 - 20 The service is able to meet service users needs appropriately and effectively. EVIDENCE: The records relating to healthcare of service users were detailed and in good order. Suitable records of daily care are maintained and provide a good picture of the care and support provided, and also record significant events and incidents. There is good evidence of other professionals being appropriately involved in supporting service users. In conversation with service users during the inspection it was possible to discuss aspects of their lives in the home and how they felt about them. One service user spoke at length about how they felt they had been able to grow and develop whilst living at Wings, to the point where they were now able to plan to move on to more independent housing. They had greatly enjoyed their time at the home and were very appreciative of the staff and all that they had done for them. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 - 23 Service users are protected and safeguarded. Staff are well trained and equipped to meet challenging needs. EVIDENCE: Specialist training has been provided to staff recently regarding challenging behaviour which is directly relevant to the care of individual service users. This is helping to reduce the number of incidents arising, and the staff team are becoming more proficient at dealing with difficult situations. There is a suitable complaint procedure in place, and the home has been able to provide evidence that the small number of complaints recorded over the last 12 months have been appropriately addressed. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 - 30 The home provides a comfortable and domestic scale environment for service users. EVIDENCE: On the day of the inspection the dining room was having a new laminated flooring laid, and so there was some disruption to the communal areas in that part of the home. The adjoining room has had a medication cupboard fitted and it is intended to further improve the facilities by fitting a sink. The original intention for the room to be an alternative communal area did not prove successful and it is now being designed as a quite room and private meeting room. Some communal areas have been re-decorated recently, and further decoration is needed in some corridors and utility rooms. The Environmental Health Service inspected the home recently and made recommendations regarding the state of the kitchen and utility room surfaces, and raised the issue of the kitchen being used as a passageway. The manager confirmed that further work is to be carried out to replace the boilers and pipework. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 16 The house clearly suffers from a considerable amount of wear and tear, which is not surprising, and the manager is aware of the need to keep on top of this problem. The handyman employed by the home has a list of work required around the home that is regularly updated by staff, and includes small jobs such as replacing the broken window catch in one of the bedrooms. Bedrooms seen during the inspection have been personalised in individual styles by the service users and were comfortable and homely. Service users spoken with during the inspection were happy with their accommodation and confirmed that they are able to exercise choice and autonomy regarding their bedrooms. The garden is well used with residents enjoying an inflatable pool during the recent hot weather. A gazebo and recliner chairs on the patio provides a very pleasant seating area. The rotary washing line has been moved from the side of the building to the larger grass area, as part of the home’s plan to re-focus daily life outdoors away from the narrow area outside the kitchen and laundry that is close to the house next door, in an effort to reduce any disturbance to neighbours by excessive noise and activity. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 36 The home is well staffed with a competent and well trained team of carers. EVIDENCE: On the day of the inspection there were 5 care staff on duty, which was more than the usual level of 4, due to the particular needs of one resident on the day. The staff team has remained stable which provides a good level of consistency to service users. An examination of staff files confirmed that recruitment procedures were satisfactory and the required checks and references on new staff are being completed. Appropriate records on staff are kept including employment, induction, training, supervision and appraisal, and identity checks. The staff induction file is quite lengthy and provides comprehensive guidance on service provision. Much use is made of questions that require written responses, and it is a very positive and balanced document. The aims and objectives of the company are promoted throughout the material contained. Staff induction includes 2 weeks spent shadowing experienced carers as supernumerary staff. Training provided recently includes sessions on Personality Disorders and Self Harming, and Moving & Handling refresher training. Examination of records Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 18 and discussion with staff members confirmed that essential training is provided, including Moving & Handling, First Aid, Food Handling & Hygiene, Fire Safety, Administration of Medication, and Health & Safety. A range of external training bodies is used, including Suffolk County Council, West Suffolk College, and the supplying pharmacist. Five carers currently hold the National Vocational Qualification (NVQ) at Level 2, which equates to 33 of the workforce. The NVQ2 award is widely recognised as the basic qualification in care, and the home should be able to achieve the target of 50 before the end of 2005. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 - 43 Service users benefit from the home being well run with a competent and effective management. EVIDENCE: The manager has recently completed the NVQ4 in Care Management, and is now considering a suitable management course to complement this, such as the Certificate in Management (CMS). The management approach to care is considered and measured, and seeks to strike a balance between service users’ independence and a proper discharging of the home’s duty of care to safeguard residents. That this has been achieved is to the credit of the staff and management. The new owners have appointed Mr Benjamin Jones as the Responsible Individual for the home, and he is supporting the management of the home, including carrying out monthly visits as required under Regulation 26 of the Care Homes Regulations 2001. Copies of the reports resulting from these Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 20 visits have been forwarded to the Commission. The home is currently implementing the changeover to the new owner’s policies and procedures to replace the existing set. The manager attends monthly operational meetings for all the company’s managers, and the changeover has been discussed in this context. Staff induction files contain information on the new parent company, which has achieved the ISO 9001 quality mark. The company has a Quality Assurance manual and this sets out how audits will be carried out, involving both internal audits, and ones involving an external agent. Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wings Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 22 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 24 Regulation 23 Requirement Some communal areas and utility rooms need re-decorating. Timescale for action 30/11/05 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 None. Good Practice Recommendations Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ 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 Wings I54 - I04 S63585 Wings V255547 050818 Stage 4.doc Version 1.40 Page 24 - 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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