Inspection on 02/02/07 for Wycar Leys The Mews Care Home

This inspection was carried out on 2nd February 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

Wycar Leys The Mews Care Home 07/02/06

Wycar Leys The Mews Care Home 09/09/05

Wycar Leys The Mews Care Home 03/08/04

Wycar Leys The Mews Care Home 25/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Wycar Leys The Mews Care Home Kirklington Road Bilsthorpe Nottinghamshire NG22 8TT Lead Inspector Wendy Taylor & Vanessa Gent Key Unannounced Inspection 19th February 2007 08:45 Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 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 Wycar Leys The Mews Care Home DS0000048275.V321506.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 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. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wycar Leys The Mews Care Home Address Kirklington Road Bilsthorpe Nottinghamshire NG22 8TT 0870 330 7522 0870 330 7521 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) Wycar Leys Limited Sally Hamilton Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: The Mews is one of four homes, for people with a learning disability, on a site a short distance away from the village of Bilsthorpe. The village has facilities such as a take away, village shop, pub and church. The home runs independently to the others on site and has its own manager and staff team. The young men who live there say that they like to be referred to as residents. The Mews provides accommodation for 10 young men. It has a large dining area, kitchen, and two lounges. There is a small enclosed forecourt and garden area which the residents have spent time personalising. The Mews shares some facilities with the other homes; these include a central kitchen, laundry, transport and extensive grounds. All areas of the home are easily accessible to the residents. The weekly fees for living at the home are £1200:00 to £2500:00 Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during February 2007; and the visit to the home was carried out over approximately 6 hours on one day by two inspectors. The care and support received by two residents was followed in detail. Residents spoke about their experience of living at the home and their care records were looked at. General house records and staff records were also looked at. Staff and the registered manager were spoken to and the care being provided was observed. Information already held by the commission was also used as part of the inspection process. Residents made comments such as ‘the staff are all good and nice’; and staff said that they were very happy working at the home. Other comments made by residents and staff are included in the main body of the report. What the service does well: What has improved since the last inspection? What they could do better: There are no requirements or recommendations made at this inspection. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive clear and accessible information that enables them to make an informed choice about where to live, and they are assured that the service can meet their needs by way of a thorough assessment. EVIDENCE: A statement of purpose and service user guide is available in individual files, and the service user guide is also available in resident’s rooms. Both documents are available in easy read words and pictures and residents sign to say they have received them. Individual contracts are also available to new residents, as well as information about advocacy services and consent issues. The residents sign to say that they have received this information. Detailed admission assessments are in individual files and contain information about needs such as behaviour, relationships, medication, sleep, activity and safety. Surveys received from residents show that they are able to make a choice about living at the home and they have enough information to help them make that choice. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from being fully involved the development of detailed and comprehensive care plans. This ensures that they receive care and support in a way that suits them, and their choices and decisions are acknowledged. EVIDENCE: Care plans are in place that address needs such as community access, independence, daily living skills, general safety, behaviour and communication. The plans are very detailed and refer clearly to issues such as dignity, privacy and choice. Plans show staff how to meet each need in an appropriate and individualised manner. Reviews for care plans and risk assessments are clearly recorded and due dates for the reviews are listed at the front of the review section for easy access. The plans cross reference with initial assessments and risk assesments. The risk assessments include information about self awareness, psychology, medical needs and behavioural motivations. Staff said that they are currently Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 10 developing a framework for person centred planning approaches, this helps residents to be able to plan for achieving their aspirations and future goals. All care plans and assessments are signed by the residents, and surveys received from residents show that they are able to make their own decisions. During the visit residents said that they can choose what they want to do and they were observed making their own choices of what they wanted to eat and where they wanted to go. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a varied social life and engage in a wide range of leisure activities of their choice. They benefit from good links with the local community and can take responsibility for their daily lives. They benefit from a healthy and balanced diet, which they can be involved in producing. EVIDENCE: Care plans are available for family access and relationship building, and the minutes of resident’s meetings show that they discuss issues such as holidays and social/leisure activities. Resident’s surveys also show that they can choose what activities they want to join in during the day, evening and weekends. There are individual activity plans available that are decided upon and signed by residents, and activity monitoring sheets are are completed by the activity co-ordinator. Records show that lots of activities are available such as gym Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 12 visits, bowling, college placements, pub visits, swimming, horse riding, arts, crafts and cinema. Residents said that they are able to to go on holidays and college tutors come to the home to do basic education courses. They also said they go to the shops, have trips out every few weeks, and do jobs like washing up and tidying their own room. One resident said that they can visit their family at weekends and another described membership of a local bowling club. There is an activity centre within the grounds, which has various activities available such as a snooker table, a music area, a pottery area and computers. There is also a go kart track and a dual assissted go kart available to residents within the grounds, and detailed risk assessments are in place for this. Minutes of residents meetings show that they are able to discuss issues such as rotas for use of the washing machine to develop independence, the home environment and they receive information on, for example, how to manage bullying. Staff said that they join in community projects like helping to update the local children’s playground, and two residents have unsupported work placements. Main meals are provided from a central kitchen and menus are balanced and varied, and they show alternatives for each meal. The house has it’s own kitchen where residents can cook meals of their choice and get whatever drinks when they want. Staff said, for example, that the residents will have a ‘curry night’ where they buy fresh ingredients and staff show them how to cook dishes. During the visit residents and staff were seen making sandwiches in the kitchen. Records show that individual diet advice is provided by dieticians. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are comprehensive health care arrangements and robust record keeping processes in place to protect residents, and provide support in a way that meets their needs and wishes. EVIDENCE: Records include information about immunisations, hearing tests, opticians, well-man clinics and medical history. Care plans include detailed information about needs such as epilepsy and general well being. There are recording sheets to show when residents have been to the dentist, chiropodist or the GP for example; and there are very detailed records, developed by the residents and containing their choices for end of life arrangements, such as choice of hymns and flowers. Staff are currently supporting residents to complete health action plans, and they said that the GP is also supporting them with this. Staff said that the GP would visit the home if residents cannot attend the surgery due to behavioural needs or, for example, if they choose not to. They have fortnightly access to a Consultant Psychiatrist who is privately purchased by the provider; and the provider also engages the services of a speech and Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 14 language therapist, who will train staff in communication methods as well as work directly with individual residents. Pre inspection information highlights that the registered manager supplies notifications to the commission as required and they contain enough detail to show that untoward situations regarding care needs are managed appropriately. Medication records were fully completed and medication storage is satisfactory. There is up to date information on the medications being used and procedures for administration are clearly displayed on the outside of the medicine storage cupboard. There are clear procedures for home leave medications and medications used only where necessary. There are also records to confirm that the resident has consented to take medication. Discussion took place with the registered manager about clearer recording of administration times for medication used only where necessary. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by clear record keeping practices and knowledgeable staff, who support them to express their views and concerns. EVIDENCE: Records show that no complaints have been made since the last inspection visit. Complaints records and general house concerns records have now been separated so that information is more easily tracked. Resident’s surveys received prior to the inspection show that they know how to make a complaint, and who to speak to if they are not happy. Advocacy information is made available to the residents (see Standards 1-5). There have been no reports of safeguarding adult issues, and records show that staff receive training in how to manage such situations. Staff demonstrated their knowledge of protection issues, and residents said that they feel safe with staff and the staff listen to what they have to say. Residents said that staff keep their money safe they just have to ask for it when they want it. They said that they sign for their money when they take it out. Care plans are available for the management of personal money. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that suits their needs and wishes, and the practices and procedures protect them. EVIDENCE: Resident’s surveys received prior to the inspection visit indicate that residents think the home is kept clean, fresh and tidy. During the visit they said that they like their rooms, and they have got their own things around them. They said that they decide what colours and décor they want. Bedrooms were seen to be very well personalised and comfortable. The house in general was very clean and tidy during the visit, and there is a cleaner employed to work in the house. Records show that maintenance work is up to date and is audited on a weekly basis by the registered manager. Staff described the use of infection control measures such as handwashing, gloves, aprons, anti bacterial wipes and sluicing facilities. Records show that staff receive training in infection control issues and the management of Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 17 substances that could be hazardous to health. Those substances were stored appropriately, and risk assessments and data sheets were available. The kitchen area was clean and tidy, as was the communal laundry. Washing machines, tumble driers and cookers are available in the house as well as the central areas so that residents can develop their skills of independence. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a comprehensively trained, well-supported and safely recruited staff team. EVIDENCE: Recruitment files are well organised and confidentially stored. They contain application forms, identification, criminal record bureau checks and references. Staff sign to say that they have received a handbook with regularly updated policies and procedures. Records of interviews are kept on file and residents are involved in the interview process. Records show that staff receive supervision on a regular monthly basis, and more frequently if needed. A front sheet contains the dates that sessions have been undertaken and when future ones are due. Staff said that they are supported by a strong management team. Training records show that staff receive training in areas such as food hygiene, nationally recognised care qualifications, medication administration, first aid, physical intervention, behaviour management, fire safety, health and safety, Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 19 risk assessing and continence. Individual training profiles show what the person has done, what they need for the future and the courses that have been booked. The training records are now kept in chronological order as recommended at the previous inspection visit, and they show that induction courses are based on specific and nationally recognised learning frameworks. The regional manager said that some staff are to be trained as assessors for the Learning Disability Award Framework. Rotas show that there are enough staff on each duty shift to meet the needs of the residents, and there is also the support of the registered manager and an on-call manager. There is some limited use of bank or agency staff but these are people that are already known to the residents. Residents said that they are treated very well by staff; and minutes from meetings show that staff are able to express their views about issues such as communication, shift patterns, team work, resident’s needs and training opportunities. During the visit staff demonstrated a detailed knowledge of resident’s needs. Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to influence the service they receive by way of a robust quality assurance process; and very good record keeping and strong leadership protect their health safety and welfare needs. EVIDENCE: Policies and procedures are available for subjects such as referrals and admissions, risk assessing, food safety and nutrition, health and safety, medication, infection control, safeguarding adults, complaints and whistle blowing. There are very clear daily notes, which refer to care plans, and there are records for accidents, violent incidents. The registered manager looks at these records individually, then they are recorded as part of a monthly house audit. All records are kept in an orderly, detailed and consistent manner, and there is evidence of regular auditing of the records. The registered manager demonstrated a very clear and detailed knowledge of the resident’s needs and Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 21 wishes; and of the skills and competence of each member of her staff team. She also showed a detailed working knowledge of the systems and principles that underpin the running of the home. Regular testing of electrical equipment is recorded as well as water temperatures. There are also up to date fire safety records, which include monthly equipment checks, weekly fire alarm checks and evacuation records. Some members of staff are trained as fire instructors and regular training updates are given on site. There are up to date environmental risk assessments available for the kitchen area, electrical equipment, fire safety, garden usage, smoking, window restrictors and activities. The quality assurance process includes an annual satisfaction survey for residents and relatives; and in response to a recommendation from the previous inspection the survey now includes visiting professionals. There are daily, weekly and monthly checklists of audits for the register manager to carry out such as personal allowances, environment, accident forms, activities, complaints, fire warden checks and vehicle audits. There is also a general overview audit for the home, with the outcomes and action plans clearly recorded. Surveys received prior to the inspection visit show that residents feel that staff listen to what they have to say and they act upon the information. Staff said that the provider is ‘fantastic’, they are always available and they want the residents to have a really good quality of life. (also see evidence in all other outcome groups in relation to residents involvement in the running and the development of the home). Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 4 4 X 4 X 4 3 x Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Wycar Leys The Mews Care Home DS0000048275.V321506.R01.S.doc Version 5.2 Page 25 - 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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