Inspection on 25/10/07 for Wishing Well

This inspection was carried out on 25th October 2007.

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 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

Wishing Well 01/11/06

Wishing Well 26/01/06

Wishing Well 04/08/05

Wishing Well 25/11/04

Wishing Well 11/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Wishing Well 37 Leven Road Dringhouses York YO24 2TL Lead Inspector Paul Newman Key Unannounced Inspection 25th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wishing Well DS0000015835.V353781.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. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wishing Well Address 37 Leven Road Dringhouses York YO24 2TL 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) 01904 337566 01904 337566 DEDEPIP@aol.com Mrs Denise Mary Thompson vacant post Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 4 01/11/06 2. Date of last inspection Brief Description of the Service: Wishing Well is a care home registered to provide personal care and accommodation for up to four older people of either gender. The home consists of a two-storey semi-detached house situated on a quiet road in a suburb of York and is within walking distance of local facilities and amenities including shops, cafes and pubs. The amenities of York city centre are also accessible by transport. The home has recently had approval for occupancy to be increased from three to four service users. All four bedrooms are for single use and are on the first floor, close to the shared bathroom. The newly registered room is en-suite. There are additional WC facilities on the ground floor. The home has a well-maintained garden and an area of hard standing for parking at the front. The registered person is the main carer and her husband and three part-time care assistants assist. The registered person and her husband live on the premises in a second floor loft conversion. Details provided during the inspection visit on 25 October 2007 outline the weekly fees as between £349 for standard single rooms and £425 for the one single en-suite. This does not include hair perms, however chiropody services, a weekly shampoo and set, if required, and individual toiletries are included. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit carried out by one inspector that started at 9:30 and finished at 15:30 on 25 October 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and that the outcomes for the people meet National Minimum Standards. Before the inspection, information collected about the home over the last year was reviewed. This included looking at any reported incidents, accidents and complaints. Survey forms were sent to the home before the inspection for the manager to give out to people living at the home, visitors, healthcare professionals involved in peoples’ care and the staff working at the home. This gives people the opportunity to comment if they want to. Information provided in this way may be shared with the provider but the source will not be identified. A good proportion of surveys were returned and some of the written comments that were made are included in the report to show what people think of the way the home is run. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information. This is a self-assessment of the service provided and this gives a lot of information about how the manager thinks the home is meeting standards, how it has improved during the last year and what it intends to do in the coming year. All of this information was used to plan the inspection visit. A number of documents that the home must keep up to date were looked at during the visit. All areas of the home used by the people who live there were checked. Time was spent talking with the people and visitors, watching what was going on, as well as talking with the manager and another member of staff on duty. There was a warm welcome given and lots of assistance and cooperation from the manager, staff, visitors and people living at the home. What the service does well: The home is well managed and the staff team are trained, experienced, properly recruited and equipped for the job. They are happy in their work and committed to providing high standards of person centred care. The needs of residents are the focus of the staffs’ attention and residents looked happy and well cared for. Staff make sure that residents are treated with dignity. Staff are also good at supporting family members who visit the home. Information about the home is readily available. People are properly assessed before they come to live at the home. This helps to ensure a good care plan Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 6 can be drawn up that identifies peoples’ needs. The home works closely with other healthcare professionals, makes referrals at an early stage and takes the advice that is given. Because the home is small, it is a very homely and family like situation and people are given a lot of one to one attention and support. Staff try to make sure people get whatever they need to make their lives fulfilled, interesting and ‘normal’. They have the opportunity to contribute to the day to day running of the home whether this is being involved in helping choose the décor, helping in the kitchen, or choosing foods at the supermarket. Written comments made in survey questionnaires returned by healthcare professionals included: • • • • • • • • I have always found the care home to be clean and friendly but professionally run, asking for help and advice from professionals appropriately and they always put into place advice given. The patients needs always appear to come first. The staff have a high level of experience and skill. The staff always act promptly. I feel the care that is given is to a high standard. The home is improving all the time with the courses that staff are attending. Clients needs come first. I have been coming to the home for 5 years and always get a warm welcome, everyone laughing. Having fun activities is a regular pastime and the clients appear happy and well cared for. Written comments made by relatives included: • • • • • • • Very well looked after, dignity, keeps the home well presented and always makes me feel welcome. As a small home it very well meets the needs of my relative. The owner is far more aware of the care needs on say a one to one basis. The owner is excellent at calling our relatives GP and liaising with the surgery. We are well satisfied with the care given and very grateful to the owner and staff. We have really appreciated the extra care and love afforded (over and above the call of duty). We appreciate the attention she gets – she really benefits from the staff knowing her – they are so warm and caring. Our relative always lets her feelings known to the staff and they respond to this. Written comments made by people living at the home, one with assistance from a relative, included: • It’s great, it’s a home and it’s comfortable – for the time being. DS0000015835.V353781.R01.S.doc Version 5.2 Page 7 Wishing Well • • Usually joins in activities always given the option. Being given excellent support with being coaxed to eat and drink. What has improved since the last inspection? What they could do better: The home continues to provide very good standards of care and some aspects are excellent. The one requirement and recommendations made below by no means affect the positive outcomes for people living at the home. Although fire alarm system checks are made by the manager’s husband each week, these must be recorded at the time the check is made as required by Regulations. Three recommendations are made: • Peoples’ case files contain a lot of historic information. The manager should consider having a current file that is used on a day-to-day basis and use another file for all archived information. This should make things easier and more manageable. Staff training records show that staff will be due up dates in safe working practice training. The manager should now start arranging for this to be done so everyone is up to date. The manager should continue with and complete the Registered Manager’s Award so that she has a recognised qualification. • • Please contact the provider for advice of actions taken in response to this Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 8 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. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 9 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 Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People have clear and accurate written information about the services provided at the home to help them choose about where to live. Peoples’ needs are properly assessed before admission, making sure their needs can be met. EVIDENCE: By coincidence, the inspection visit was made at a time when a prospective service user and his family were visiting the home to assess if it was going to be a good place to live. Following explanation about the inspection visit, the family were happy for their visit to be observed to see how the manager explained things and what information was given about the home. The Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 11 information provided in the Annual Quality Assurance Assessment (AQAA) with regard to pre-admission processes stated: ‘I visit the prospective resident for a chat and tell them about our home. I complete the needs assessment form which includes information such as personal care needs, physical well being, diet and weight, dietry preferences, sensory impairments, oral health, foot care, mobility and dexterity, history of falls, continence and medication. I leave the prospective resident our statement of purpose and service users guide. The resident then comes for a visit, because we firmly believe the resident should be given the choice of whether or not they want to live here. We collect all the necessary documentation from the relevant care professionals and ensure the resident’s physical and emotional needs are met’. In the case of the person visiting on the day of the inspection, his family members had visited a number of homes but his son had visited Wishing Well the day before. The family said that the son had been impressed and had arranged for a quick visit for his father with other family members to see the home. The manager dealt with the family and prospective user in a really sensitive and informative way. The way the home operated was fully explained and the family were given the service user guide and invited to see other compliments and details about the home. Their questions were answered fully about how the day was organised, visiting, contact with the family - reassuring him he could still get out to his weekly jazz club with his son, activities in and out of the home, food and what the next stage in moving into the home would be. A further visit was arranged for the following week when the perspective service user was coming for tea and more details about his care needs and history would be sought and recorded. The visit was very reassuring for the family and service user, with all expressing the view that because of its size, and the flexibility that was offered and above all the family atmosphere, this was just what they wanted. The file of one person who was staying at the home for a weeks respite for the first time (the only admission since the last inspection), was checked to see if sufficient information had been gathered prior to her admission. Relevant needs assessments and care plans were on file and in conversation with this person she said ‘I suit the home’. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 12 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. People who use the service experience excellent quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ healthcare needs are met and care plans provide clear instruction for staff to follow. Staff are aware of peoples’ needs and there is good communication amongst the staff group and with healthcare professionals. Medication policies, procedures and practices are safe. People are treated with respect and in a dignified way. EVIDENCE: Apart from the person living at the home for respite care, one other file was checked to make sure the care needs had been identified, were reviewed each month or sooner if necessary and guidance was given to staff about how to meet those needs. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 13 The home has no lift or stair lift so the levels of mobility of people living at the home need to be good and regularly monitored. Other care needs were identified in the plan and reviewed monthly. The AQAA stated: ‘We promote mobility and independence at all times. We promote continence and have a successful record of maintaining and improving mobility and continence. Residents are bathed/showered as often as they want, personal care is individual and tailored particularly to each resident. A high quality of oral care is maintained and we have regular visits by the chiropodist. Regular optical checks are carried out within the home by the optician. We have regular hairdressor visits to maintain self esteem’. The care plan seen was very person centred and this is one of the most positive features of the home. With a maximum of four people, the manager and staff know the people in their care extremely well. Personal preferences across the whole range of aspects for daily living are identified in the plan and known by the staff. But, even though individuals’ routines and preferred ways of going about things are known, the conversations during the visit showed that there was a great deal of flexibility on top of this. The file showed contact with healthcare professionals and the entries documented the reason for the referral and the outcome. Written comments made in survey questionnaires returned by healthcare professionals included: • • • • • • • • I have always found the care home to be clean and friendly but professionally run, asking for help and advice from professionals appropriately and they always put into place advice given. The patients needs always appear to come first. The staff have a high level of experience and skill. The staff always act promptly. I feel the care that is given is to a high standard. The home is improving all the time with the courses that staff are attending. Clients needs come first. I have been coming to the home for 5 years and always get a warm welcome, everyone laughing. Having fun activities is a regular pastime and the clients appear happy and well cared for. Written comments made by relatives included: • • • Very well looked after, dignity, keeps the home well presented and always makes me feel welcome. As a small home it very well meets the needs of my relative. The owner is far more aware of the care needs on say a one to one basis. DS0000015835.V353781.R01.S.doc Version 5.2 Page 14 Wishing Well • • • • The owner is excellent at calling our relative’s GP and liaising with the surgery. We are well satisfied with the care given and very grateful to the owner and staff. We have really appreciated the extra care and love afforded (over and above the call of duty). We appreciate the attention she gets – she really benefits from the staff knowing her – they are so warm and caring. Our relative always lets her feelings known to the staff and they respond to this. Written comments made by people living at the home, one with assistance from a relative, included: • • • It’s great, it’s a home and it’s comfortable – for the time being. Usually joins in activities always given the option. Being given excellent support with being coaxed to eat and drink. Medication is stored in a locked cupboard in the dining room making it easy to administer drugs at appropriate times. The home uses a monitored dosage system – drugs dispensed in blister packs by the pharmacy. The systems of ordering, checking in and disposing of drugs was discussed and records were checked. The lunchtime medication was administered properly and recorded. The drugs administration charts showed no omissions. Written comments made in the surveys that were returned mentioned that peoples’ dignity was maintained. A good proportion of time was spent during the inspection visit watching staff practices. This showed that they know the care needs and personal preferences of individuals and are good at identifying non-verbal behaviour that indicates when a resident is happy or unhappy. They were good at making sure nobody was isolated and got as much positive attention as possible. The relationships between staff and the people they care for are warm and friendly with people obviously enjoying some physical reassurance like holding their hand as staff spoke with them. Clothing was clean and all of the residents looked well cared for with their hair attended to, ladies ‘made up’ and nails polished. Staff were attentive to people and some overheard conversations showed staff to have a nice manner that people appreciated. People were clearly happy and at ease in their home. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their daily routines. People living at the home are provided with a varied and nutritious diet. EVIDENCE: The person centred approach of the home means that where possible activities are individually organised. The AQAA stated: ‘We provide as near to a familiar and normal social life and also maintain life and social skills. We provide an environment that is people centered. Our residents always do well and improve greatly. We have regular trips out and Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 16 we encourage new and old interests. We offer plenty of diversity in our home life. We work with feedback from residents families and friends as well as the residents themselves. As a four bedded home we are able to rise to any challenge that occurs, so we are continually improving our service and working with residents to offer a stimualting daily life. We always listen and try to involve residents in all daily living activities for example our residents help with choosing the food on the shopping list to suit their personal tastes’. Conversations during the visit confirmed that this was the approach. One person, much to the amazement and delight of her daughter, has been helping out in the kitchen by peeling potatos. People may choose to wash up a few dishes or fold some of the clean laundry. The manager feels it is important that the residents can still contribute to the running of the household if they wish. It is this kind of approach that makes the home almost unique in the care home sector for the elderly, in being able to offer as normal a home situation as possible. The manager has made sure that musical and television tastes are well catered for by buying specific items according to individual preferences. There is an assortment of books, games, CDs and DVDs evident, though television is still a popular choice. One member of staff is introducing art and craft activities that prove popular. The manager has a large static caravan at the coast, and people are able get away for weekends. If they choose not to go there, then staff would be available to enable them to stay at home. This is detailed in the written information about the home. There are lots of photographs in various parts of the home, which provide talking points about previous events and evidence of enjoyable times in and out of the home. The home has a dog, two cats and a parrot, which also provide diversion and entertainment. There is a dovecote in the garden, a summerhouse, patio furniture and a barbeque. The surveys that were returned all showed that visitors are made to feel welcome and that contact with family and friends is encouraged. This was further reinforced by the example of the person visiting the home who, together with his family, was reassured that he could have as much contact as he wished and get out to his jazz club with his son. People are encouraged to be as independent as possible and make choices about the way they live, dress and use their time. While their personal preferences are known, there is also a good deal of flexibility for people to have an extra lay-in in the morning, an extra bath, in fact the impression was given that if someone wanted to do something a little different to the norm, staff would accommodate this. People are involved in talking about the weekly shopping to see if there is anything they ‘fancy’ and if they wish can get out to the shops with the Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 17 manager – just like home. There is no set menu but there is a record of the food provided. The food prepared is based on what is fresh and available in the shops, what the people like and to some extent the weather, but always with an eye on it being good nutritious food. On the day of the inspection visit, it was a colder day so there was a good wholesome casserole prepared. Vegetables are always fresh. Pudding is what you fancy that day. Breakfast is also what someone wants that day, as is the tea. People can have a drink or a snack of their choice when they wish. The flexibility of this approach means that ‘off the cuff’ barbeques can be held if people want it. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 18 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. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people who live at the home and their relatives feel confident that they will be listened to and things made better when necessary. People can be assured that they can feel safe at the home as there are adult protection procedures that staff have awareness of and understand. EVIDENCE: The AQAA stated: ‘Because we are small we can see potential problems at source, before they become actual problems and because we offer one to one care, we can be aware and tuned in to our residents requirements, needs and wants. We also have a comprehensive complaints policy that is available to anyone who needs it’. There have been no complaints to the home or Commission since the last inspection. The complaints policy is displayed in all the bedrooms, as well as in the Service User Guide that is given to service users and their families. The surveys that were returned to the Commission all indicated that people and their relatives know how to complain formally but also indicated in some of the Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 19 written comments that people feel comfortable in raising concerns and feel that staff listen and act positively. Family members visit on a regular basis and are able to check on the welfare of their relatives. The surveys suggest that the home is good at communicating with families and keep them informed of problems. The size of the home means that the manager and staff are able to sit and talk with people and visitors each day and check that all is well. Peoples’ happiness and welfare are the main concerns of the staff. There is an adult protection procedure and staff have access to this and have received training. Since the last inspection the manager has attended workshops on the Protection of Vulnerable Adults. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 20 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. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People live in a safe, comfortable and well-maintained environment. EVIDENCE: The building is a semi-detached house that has been extended. On the day of the inspection visit a contractor visited the home to measure up for a new patio window that will lead to a new conservatory. The environment is domestic and homely. Furnishings and fittings are of good quality and the building is well decorated. Where changes are planned, like the conservatory or redecoration, these are discussed with people living at the home so that they can feel involved. Bedrooms are decorated to their personal taste with coordinated curtains and bedding. Bedding is replaced regularly and any new Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 21 person always benefits from new bedding and this was the case for the person in for a weeks respite. The manager said this would be replaced again after the person leaves. The bedrooms are personalised with furnishings and belongings like photos and ornaments belonging to individuals. Since the last inspection the lounge, kitchen and dining room have been redecorated. Also, occupancy has increased by one, the additional bedroom being the previous en-suite accommodation on the first floor used by the owners. They now live in a loft conversion. This is linked to the emergency call system so that if anyone needs assistance during the night the owners are alerted. This was fully explained to the prospective service user and his relatives. There is no stair lift, so residents have to be able to manage the stairs. There is a made to measure safety gate at the top of the stairs that is used at night for additional safety. People can assist in the kitchen but this is always under supervision to reduce risks. The kitchen has been extended and adequately caters for the needs of the home and can provide an additional space for people to come in and have a chat with staff at the kitchen table. The gardens to the rear of the building are a good size and are safe for people to sit out and wander around. There is a patio area, a summerhouse, a dovecote, bird tables to provide interests for people and well-kept flower borders and a barbeque area. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 22 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. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living in the home are cared for by experienced staff who are recruited properly and trained for the job. EVIDENCE: During the inspection visit a large part of the time was spent in the communal areas watching staff at work including during the mealtime. There were certainly enough staff on duty with the manager and a carer, so people got plenty of individual attention, support and encouragement with a lot of checking to see if they were happy. Most of the staff have worked at the home for a lengthy period and know the people they care for extremely well and this counts for a lot in the relationships and consistency of care. The surveys returned by each of the staff working at the home, showed that they felt that they had been properly trained and a conversation with one on duty appointed around the time of the last inspection showed that she had been through an induction period. Staff have been following a course on dementia care to extend their knowledge of the elderly. If anything, the staff training records indicate that some safe working practice training is due for update and this Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 23 should be organised. This had been identified as a need for improvement in the AQAA that was returned. The staff files seen were organised and the recruitment documentation showed that staff had been properly vetted and checked. The member of staff on duty said that it was a great place to work and that view was reflected in the surveys that were returned. Despite the family atmosphere and domestic situation, the home has not lost any professionalism and has organised shift handovers, staff meetings and one to one supervision sessions and appraisals. The surveys that were returned by healthcare professionals, people using the service and their relatives all show that the manager and staff are held with high regard for the level of personal support that is given. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the manager and her staff. There is a clear approach to resident care that is person centred and puts the best interests of individual residents central to staff practice. Regular auditing and checking of facilities, equipment and services make sure the home is a safe place to live. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 25 EVIDENCE: It was clear from the survey results and conversations with people that the manager is a good leader and well respected. The manager has owned the home for several years and is very experienced in caring and supporting older people. She is studying for a Level 4 National Vocational Qualification. She has a very good relationship with people and is able to anticipate many of their needs. She finds out their views about the service, and those of their family informally in conversation, but people are also invited to complete a satisfaction survey questionnaire. The completed surveys are held on individuals’ files. The home does not have any responsibilities for holding service users’ monies, and if the manager buys items on a resident’s behalf, the cost is invoiced to the family. People have lockable items of furniture to keep valuables and can lock their rooms if they wish. The AQAA indicated that relevant health and safety and infection control policies and procedures are in place, and that regular checks are made of facilities and equipment. There were risk assessments in place for the environment. The owner’s husband holds the responsibility to check the fire system each week and conversations with people confirmed that this is done. The tests must however be recorded at the time the test is done, it had been several weeks since the test had been recorded. Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 26 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 27 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 OP38 Regulation 17 Timescale for action Although fire alarm system 30/11/07 checks are made each week, these must be recorded at the time the check is made as required by Regulations. Requirement 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 OP7 Good Practice Recommendations Peoples’ case files contain a lot of historic information. The manager should consider having a current file that is used on a day-to-day basis and use another file for all archived information. This should make things easier and more manageable. Staff training records show that staff will be due up dates in safe working practice training. The manager should now start arranging for this to be done so everyone is up to date. The manager should continue with and complete the Registered Manager’s Award so that she has a recognised qualification. 2. OP30 3. OP31 Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Wishing Well DS0000015835.V353781.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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