Inspection on 12/01/06 for Wren Park Nursing And Residential Home

This inspection was carried out on 12th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wren Park Nursing And... 21/11/08

Wren Park Nursing And... 07/12/06

Wren Park Nursing And... 25/08/05

Wren Park Nursing And... 17/02/05

Wren Park Nursing And... 11/06/04

Wren Park Nursing And... 27/01/04

Wren Park Nursing And... 22/12/03

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Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Wren Park Nursing And Residential Home Hitchin Road Shefford Bedfordshire SG175JD Lead Inspector Ms Louise Trainor Unannounced Inspection 12th January 2006 12:45 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 Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 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. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wren Park Nursing And Residential Home Address Hitchin Road Shefford Bedfordshire SG175JD 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) 01462 851548 01462 850667 GA Projects Limited Mrs. Elizabeth Mazhar Care Home 46 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (46) of places Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users must not exceed 46. No one falling into the category of DE(E) may be admitted into the home where there are already 15 persons of category DE(E) accommodated in the home. To continue to accommodate the person aged 62 accommodated under category OP and who was named in the proposal to vary the conditions of registration. No other person under the age of 65 years of age may be admitted to the home. 25th August 2005 Date of last inspection Brief Description of the Service: Wren Park was registered to provide for residential and nursing services to forty-six persons over the age of sixty-five years. Fifteen of the places were registered for those with dementia. The registration also included forty-six places for those with a physical disability. Satisfactory arrangements were in place to refer service user to health care specialists as need be and to provide a comfortable and supportive service. The service included the provision of meals, laundry services and in house activities provided by a delegated organiser. A registered nurse managed the home and sufficient other nursing staff were employed to provide a qualified person on duty at all times. Adequate care and ancillary personnel were employed. The home is situated at a short distance from the market town of Shefford. The building comprised the original old house that had been suitably adapted and had a large extension, purpose built to provide residential care. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 12th of January 2006 over a four - hour period. The inspection commenced at 12:45 hours and was completed at 16:55 hours. The home manager was present throughout the inspection to assist. During the inspection a case tracking methodology was used. Two service users were selected at random, their personal files were inspected and the inspector viewed their personal living areas. Time was also spent observing and talking to these service users, and staff that were interviewed, were invited to demonstrate their knowledge of the individual care they provide to these particular service users. This was the second inspection of the year and focused primarily on the progress made in meeting the requirements made at the last inspection that took place in August 2005. Outstanding key standards including: Dying and Death, Protection, Staff Compliment, Training, Recruitment, Quality Assurance and Service User Money were also inspected. The home presently has forty-one service users. Fifteen of these are in residential care and twenty-one requiring nursing care. One of the step down beds is in use. The home has five vacancies. The inspector would like to thank all staff and service users for their support and assistance during the inspection. What the service does well: The home promotes a warm and homely atmosphere. The service users all appeared happy and comfortable. Some were relaxing after their lunch, watching television and chatting with visitors, and others were involved in, and thoroughly enjoying a gentle exercise group. There was friendly interaction between staff and service users observed. The home has two qualified nurses on duty at all times. The home has no staff vacancies at the moment. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 6 The menus appear varied and nutritional with a good choice available at all mealtimes. This includes alternatives for special dietary needs. Sundries such as jacket potatoes, omelettes and salads, fresh fruit and cakes are always available. Service users personal living areas are decorated and furnished to individuals’ tastes reflecting their choices and personalities with photographs and other personal effects. One service user had statues of Laurel and Hardy sitting on a bench, situated in the corner of her bedroom. Which although apparently unnerves the carers from time to time, clearly reflects her sense of humour. What has improved since the last inspection? What they could do better: The home needs to review their training programme to ensure all staff have a better awareness of dementia, it s sufferers and ways to meet their needs more effectively. The home must ensure all staff have an enhanced CRB clearance or POVA first check prior to working in the home. Care planning should be extended to involve care staff of all levels to ensure continuity of care at all times. At present none of the bedrooms have locks on them, the home should consider that this maybe taking choice away from some service users. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, The home has a good admission procedure with sufficient information so that service users are assured their needs will be met. EVIDENCE: There is evidence of signed contracts in the service user files, indicating that they have been read and understood by themselves or their families. There was a copy of the Service User Guide in each of the files viewed. This still requires some additions to include the views of the service users, and the CSCI s report, or instruction on where it can be viewed. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10, 11, There are robust procedures in place to ensure that at the time of death, service users and families wishes will be met with sensitivity and respect. All service users have a clear and detailed plan of care so that their health, personal and social care needs are met. EVIDENCE: The home has recently sent out a letter to all service users and their families. This sensitively requests any specific instructions or wishes to be carried out in the event of death. Personal files were seen to have signed responses in them. Each service user has individual care plans in their files. These clearly identify the needs of the individual, but could be improved to include a clearer instruction of how they should be met. This would ensure continuity of practice. Each service user file also has a form signed by themselves or a relative to indicate they are aware of, and in agreement with the plan of care. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 11 All service users requiring bed rails for safety purposes have a signed sheet indicating agreement. One service user told the inspector: ‘I like it here. I spend all my time in my room; I’m a private person and like my own company. It s a good nursing home, visitors can come when they like. The staff and matron are all very good’. It was observed that none of the bedrooms have locks on the doors. Although no comments regarding this were made by service users during this inspection, it could be viewed as contravening service users’ rights to choice and privacy. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 There is a varied activities programme in place so that service users social and recreational needs are met. The home offers a varied and nutritional menu ensuring that service users are able to exercise choice and control over their own lives. EVIDENCE: Menus were observed to give choices at every mealtime. Jacket potatoes, salads, omelettes, fresh fruit and other sundries were available at all times in addition to the listed menus. Bedrooms and personal spaces that were seen were decorated with individual taste. Many had photographs and other personal effects on show giving visitors an understanding of the service users as individuals. One service user had a large statue of Laurel and Hardy on a bench, in the bedroom. This clearly reflected her personality and sense of humour. A gentle exercise session to music was observed. There were seven service users participating, all appeared to be relaxed and enjoying the experience. An organiser who was clearly experience was delivering the session sensitively. This was refreshing to see. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The systems in place for the Protection of Vulnerable Adults are insufficient so that service users may not be protected. EVIDENCE: One member of staff that was interviewed could not demonstrate a clear understanding of POVA. Another member of staff had done POVA training, but only as part of an NVQ module. The home have a POVA training session booked with another local home owned by the same company. One service user stated she would not know where she could find a copy of the complaints procedure, although did emphasize that she has nothing to complain about. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26. The home promotes an environment that provides safe, comfortable surroundings for the service users. EVIDENCE: The home was clean, homely and free from any offensive odours. All bedrooms visited were noted to be furnished with personal effects and photographs. Moving and handling equipment was visible around the home, although this was not seen in use during this inspection. The home is set in beautiful gardens, although at this time of year could not be appreciated to its full potential. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 The homes recruitment policy is insufficient to ensure that the service users are protected. EVIDENCE: Staff files indicate that staff recruited abroad, have commenced work without either an enhanced CRB clearance or a POVA first check. Although there was a certificate from the Penalty Register relating to their country of origin. One carer explained that she had ‘worked for two to three weeks as an ‘extra’ when she first came into post. During this period she had undergone informal training in: bathing, bed-making, feeding, fire, cleaning residents and dressing. However there was no induction documentation to support this. Staff numbers have increased to ensure the following levels are maintained: Nine staff – 08:00 hours – 14:00 hours Eight staff – 14:00 hours – 20:00 hours Four staff – 20:00 hours – 08:00 hours These numbers include two qualified staff at all times between 08:00 hours and 20:00 hours. The home caters for service users suffering from dementia, however there is presently no training on this subject available. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 The home has procedures in place to ensure service users’ financial interests are safeguarded. The home has quality assurance systems in place to ensure the home is run in the best interests of the service users. EVIDENCE: The manager has been in post for an established period of time. Both staff and service users stated that she was well respected, approachable and easy to talk to. Although not directly responsible for budgets, the manager confirmed that she has never had any problem securing funds for any required project or purchase. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 17 All service users keep a small amount of money in the home. This is stored in individually named containers, in a locked cupboard, in a locked storeroom. Only the owners and the manager have a key. Records were viewed and all deposits and withdrawals have two signatures. Three service users accounts were check, and reconciled appropriately. During the past six months the home has carried out audits in: Food, cleanliness, wheelchairs, infection control and service user questionnaires. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 18 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X X Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 (1) Requirement Timescale for action 31/03/06 2 3. OP18 OP29 13(6) 19 (4) (c) 4 OP30 19(5)(b) Arrangements must be made to develop the care plans for the service users with nursing needs. These must show the care interventions to be carried out by the care staff.(previous timescale of 30/10/05 not met) The manager must ensure all 31/03/06 staff undertake training in the Protection of Vulnerable Adults. Arrangements must be made to 31/03/06 ensure satisfactory recruitment procedures are in place to ensure clearances are sought for all employees prior to them commencing employment at the home.(previous timescale of 30/10/05 not met) The manager must ensure that 31/03/06 all staff undertake some training in Dementia awareness. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 20 No. 1. 2 Refer to Standard OP1 OP24 Good Practice Recommendations The service users guide should be developed to include the service user views and CSCI report. All service users should be given the opportunity of having a lock fitted to their bedroom door, to enable them to keep valuables safely in their own rooms if they so wish. A key must be offered to those service users wishing to lock their bedroom doors. Wren Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Park Nursing And Residential Home DS0000017698.V275953.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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