Inspection on 04/11/05 for Wren House

This inspection was carried out on 4th November 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wren House 02/08/07

Wren House 07/07/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Wren House 1-3 Wren Avenue Malvern Worcestershire WR14 2QB Lead Inspector Martha Nethaway Unannounced Inspection 4 & 6 November 2005 02:45 Wren House DS0000064834.V265949.R01.S.doc Version 5.0 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 Wren House DS0000064834.V265949.R01.S.doc Version 5.0 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 Adults 18-65. 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. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wren House Address 1-3 Wren Avenue Malvern Worcestershire WR14 2QB 01684 574278 0207 608 3254 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) Royal Mencap Society Candice Lancaster Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of registration: Date of last inspection Care Home. LD Learning Disability - 8 LD(E) Learning Disability (over 65) – 8 25/5/05 Brief Description of the Service: Wren house is a small home for eight adults with learning disabilities with a age range from mid twenties to mid fifties and one person is over 65. The property is converted from three houses on the end of a terraced row and is located on a mixed housing estate. The layout of the home provides partially separate living arrangments. This is not being currently used. The registered provider is the Royal Mencap Society. The responsible individual is Ms Janine Tregelles. The service manager is Mr T. Hickey who provides line management support and supervision to the registered manager. The registered manager Candice Lancaster is in post. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and occurred over two days. Beginning on a Friday afternoon for 2hrs and again on Sunday morning for 1½ hours. The inspector had discussions with service users, staff and examined records and policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 7 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 the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 6, 7 & 9 Clear arrangements exist to promote and safeguard the needs of service users. Risk assessments were well carried out. Support plans should be implemented to properly address care and support needs. Access to advocacy services should be improved. Files should comply with the expectations of the standards in relation to records being kept in the home. EVIDENCE: Two service users’ files were examined. There was a formal assessment that briefed staff about essential information related to an individual’s care needs. The external line manager had directed the manager for a time-limited period to put into effect ‘Service User Plans’. It was disappointing that service user’s plans had managed to drift but Mencap were addressing this issue. It was intended to have all service user’s plans implemented by November 2005. It is recommended that the manager conducts a self-audit to check that service user’s files fully comply with the National Minimum Standards (NMS) in relation to the expectations of records to be kept for each service user. One service user described their involvement in relation to being consulted about their care plan. This included discussions about the content, pictures, Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 9 and style and layout of the written care. ‘I felt involved with my plan with the staff member’ was the comment expressed. There was evidence that assessment of skills and ability were considered. All service user’s plans include an analysis of risks and any limitations are well documented. The manager will need to ensure consultation occurs about the care plans with service users families and/or advocates. The care plans will also need to be kept under review at least every six months. Discussions with two service users evidenced they felt staff listened to them. Staff described how they enable decision-making and were sensitive to the needs and abilities of service users. The manager needs to address how advocacy will be developed in the future. How it is to be accessed and promoted within the home. This is especially important, as a number of service users need specialised support to articulate their opinions, independent of the staff group. Greater focus needs to be given on how individual choices have been made and to record incidents when others make decisions. Mencap provided a clear process to address risk management. The staff team had ensured risk assessments were completed and consideration had been given to addressing skills development and the promotion of independent lifestyles. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 13 &15 The home is able to support individuals to pursue leisure and recreational interests. Established links were formed with service users families and friends. External agencies are involved in providing specialised input with service users. A clear keyworker system exists to provide one to one quality time with service users. EVIDENCE: Two service users were able to describe their leisure and recreational activities. Particular interests included trips to the local pub, playing at dart events, rambling and attending the local cinema and theatre. A number of the service users maintain regular contact with their relatives including home visits. Staff were able to facilitate this including arrangements for transport. Two service users are members of a weight watcher club and are now developing additional social networks and friendships. The manager highlighted that a number of the service users opted not to regularly access community resources. Service users themselves determined this and it is recommended this should be recorded during the review process. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 11 A particular strength of the home is the involvement of family members and relatives. Some of the service users talked about their arrangements to visit their families and one service user was on holiday with a relative. Service users were provided with one to one time with a keyworker. Keyworkers prepared a monthly summary of significant events with individuals. One service user spoke favourably about the time and effort that their keyworker had shared with them. External input from psychiatric health service continues and the staff team are liaising with a sexual health co-ordinator based at the local primary care service. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 18 Staff were able to support and meet the care needs of individuals. Service users independent skills are identified and promoted. The management have the capacity to highlight changing needs of individuals and review staffing arrangements to match. EVIDENCE: During the inspection, staff were observed to be sensitive to needs of service users and able to respond to specific requests. Service users were observed to be able to spend time on their own and sought staff for advice or help when needed. Not all of the service users were there as four service users were away on holiday. The atmosphere experienced by the inspector was relaxed. A number of the service users require minimal support and supervision. Two of the service user’s needs are changing and this had been discussed in recent reviews. The placing authority is reviewing the funding arrangement to increase the fee in order to permit the home to provide extra staffing. The staff team had welcomed this additional resource. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 23 There was a policy and procedure on the Protection of Vulnerable Adults implemented within the home. EVIDENCE: A policy on Abuse Prevention and guidance on the Protection of Vulnerable Adults (POVA) was available at the home. Training had been provided and during the staff induction process adult protection is extensively covered. Mencap training department had also issued updated guidance in relation to the POVA register and the expectation and duties of the employer and employee. There were no live issues in relation to adult protection. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 14 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 the following standard(s): EVIDENCE: None of these standards were examined on this occasion. The previous requirement in relation to the refurbishment of the home has not yet been met. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 The recruitment practices were consistent with the home’s policy and procedure. The management team are suitably qualified in care. Staff training for new employees was well prepared. Better arrangements need to be in place to make certain all staff receive at least five training and development days per year on completion of 12 months of service. EVIDENCE: Recruitment practices were examined. The files were comprehensive and well organised. All the staff files examined contained appropriate evidence relating to recruitment checks. Previous employers written references were available. As a good practice measure, the manager should take up a telephone reference to validate the authenticity of the reference from previous employers. A record should be made of this. Job descriptions and written explanation of gaps in employment were evidenced. All employees are subjected to a six-month probation period with an initial 3-month review. The home has employed a volunteer and all the necessary checks had been completed in conjunction with a formal ‘Volunteer Form’. The manager intends to involve service users more directly with the recruitment of staff to the home. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 16 The training records were checked and discussions with the registered manager indicated there was a planned approach to staff training. Mencap training department provide a detailed induction programme for all new employees. The deputy manager is currently undertaking NVQ 4 in Care and the registered manager had completed her ‘Registered Managers Award’. The only area identified as leading to a shortfall is how the service intends to ensure that each staff member has at least five paid training and development days (pro rota) per year. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 There were a variety of mechanisms in place to consult with service users. Further consideration should be given to how service users receive feedback in relation to house meetings. Suitable arrangements are in place to ensure that health and safety was being regularly monitored. EVIDENCE: There were systems in place to ensure that service users are being regularly consulted. These included keyworker meetings and one to one time spent with service users. Records were seen of house meetings and a variety of topics were discussed. It is recommended a response to actions at previous meetings be clearly recorded. Residents meetings should be a standing agenda item feature of the minutes of staff team meetings. The registered manager intends to invite a service user representative to participate for part of the staff team meeting to share and discuss issues relating to the home. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 18 Regular questionnaires were being circulated to service users and family members. Progress had been made in addressing the previous requirements and recommendations of the last inspection. Mencap have a number of policies and procedure that addresses matters in relation to health and safety. All the necessary checks were in place for fire safety, utility checks, food hygiene, infection control and risk assessments. The environmental health officer had visited the premises in mid October 2005 and no action was required following this visit. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 19 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 x x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wren House Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x DS0000064834.V265949.R01.S.doc Version 5.0 Page 20 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 YA6 Regulation 15 Requirement Service user plans must be drawn up with each service user in accordance with the requirements of Regulation 15 and Standards 2 and 6. Plans must be kept under review. (Previous timescales not met (31/10/04 & 16/5/05 & 31/8/05). The Provider must ensure that the home is decorated to a acceptable standard in the kitchen areas, the second shared communal areas and the laundry room. Previous timescales not met 31/8/05). Timescale for action 31/01/06 2 YA24 23 30/04/06 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 YA6 Good Practice Recommendations A review of the service user’s files should be conducted to ensure full compliance with all the matters identified in Schedule 3 of the National Minimum Standards Care DS0000064834.V265949.R01.S.doc Version 5.0 Page 21 Wren House 2 3 4 5 6 YA7 YA13 YA34 YA35 YA39 Homes Regulations. Consideration should be given to the value of advocacy services in helping service users express their views of the service and any concerns they might have. Service users reviews should record where individuals have determined not to participate in accessing local community resources. Telephone references should be obtained from previous employers that validates authenticity of the potential employee. Each staff member should receive at least five paid training and development days (pro rota) per year. Service users should receive feedback about the action points from residents meetings. Residents meetings should be a standing agenda item feature of the minutes of staff team meetings. Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Wren House DS0000064834.V265949.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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