Inspection on 09/09/05 for Wycar Leys The Mews Care Home

This inspection was carried out on 9th September 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wycar Leys The Mews Care Home 02/02/07

Wycar Leys The Mews Care Home 07/02/06

Wycar Leys The Mews Care Home 03/08/04

Wycar Leys The Mews Care Home 25/05/04

Similar services:

Hillside

Applegarth

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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) Kirklington Road Bilsthorpe Nottinghamshire NG22 8TT Lead Inspector Lee West Unannounced 9 September 2005 - 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wycar Leys (The Mews) Address Kirklington Road Bilsthorpe Nottinghamshire NG22 8TT 0870 330 7522 0870 330 7522 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Wycar Leys Limited Sally Hamilton Care Home - Private 10 Category(ies) of LD Learning Disability 10 registration, with number of places Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd August 2004 Brief Description of the Service: The Mews is one of four homes situated within large grounds and a short distance from the village. The home runs independently of the others and has its own staff team. Food is prepared for service users in the main kitchen and then transported to the home and service users use the kitchen within the home to prepare small meals. There is a small enclosed forecourt and garden area which the service users have spent time personalising. The home has its own vehicle and access to an additional shared vehicle. The service users are male only. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 9.45am and was over four hours, by one inspector with support from a Regulation Manager for part of the inspection. 3 Service users were spoken with about their experiences and expectations of living at the home, with analysis of the records and talking with 3 members of staff to ensure that those living at the home have their needs met and their health and welfare maintained appropriately. This method is referred to as Case Tracking. Assisting with the inspection was the unit’s Manager Sally Hamilton. Overall the home has developed a homely, personalised environment for the service users, who at the time of inspection were involved in numerous activities, inside and outside the home and in the local community. The staff team works with the service users to promote independence and personal development. What the service does well: What has improved since the last inspection? The service users are encouraged to participate in activities that can lead to increased independence, some service users carried out unsupervised work within the local community, others have attended college courses. Activity timetables are negotiated with the service users. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed at this inspection EVIDENCE: Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Service users are aware of the personal goals and assessment of needs in their individual care plans and that this information is kept confidentially, take part in chores and activities around the home, make decisions and live as independent a lifestyle as possible. EVIDENCE: Service users work with the team leaders and activities organiser to negotiate and implement individual plans to address their needs and goals. These plans are usually signed, though some at this inspection have signatures missing. Work within the house is carried out by everyone and there is a rota for the routines like lunches and cleaning. Wednesday is identified for cleaning personal rooms. The service users have built a smokers shelter and at the time of inspection were repainting the garden furniture. Service users are included in the interview process for new staff as recorded in the interview notes for new staff. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16,17 Service users’ personal achievements and development are recognised and they are involved in the local community for work and leisure activities. Their rights are respected and accepting responsibilities encouraged. Meals are enjoyed by service users. Staff responses to service user comments about sexual relationships are not always conducive to supporting the service user. EVIDENCE: There are a number of achievement certificates and photographs of service users receiving awards around the home, and in service users bedrooms. The activities timetable negotiated shows evidence of service users taking part in activities that are appropriate for their age and peer groups. Activity Manager and service user input to identify activity changes and choices whether to follow timetable when reviewing activities would support negotiated planning. Some of the service users have work within the local community, working unsupported, and also enjoy the leisure facilities available, swimming, café and pub are amongst these. One service user spoken with talked about his work within the community. Family contact is encouraged and the care Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 11 plans record this. One service user explained he had been to his relations. Sexual relationships are not evident, however some service users expressed their sadness at not having “lady friends”. Staff, as recorded in the care plans, have not always appropriately responded to normal, appropriate, personal statements of a sexual nature to support the service user to express their feelings in this area. Main meals are provided from the central kitchen, but the service users prepare some of their own meals, breakfast during the inspection. Service users follow a rota for this activity. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 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 standard(s) 18,19,20 The service users are supported in the way they wish and their physical and emotional needs are mostly met. Medication is administered by the staff and the medication is stored and recorded accurately. EVIDENCE: The Care Plans and rapport between the staff and service users identify the support required, offered and accepted. The physical and emotional needs are addressed and, except for the area of sexual feelings expressed by some service users, are met. The care plans of service users tracked had records which showed a reduction in the episodes of negative behaviour, which is an indicator that needs are being met. The medication is kept in a locked office and cupboards in accordance with the requirements. All medicines are signed and the Medicine Administration Records for the service users case tracked were completed correctly. Medicines stored were labelled, dated and stored correctly. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 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 standard(s) 22,23 Service users are listened to and their views are acted upon. The Home responds appropriately to any allegations of abuse. EVIDENCE: Service users spoken with said they could complain, or tell the staff anything, and it would be dealt with. This was observed during the inspection between one service user and a member of staff. The Home has a clear Protection of Vulnerable Adults policy, which, records show, is followed. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 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 standard(s) 24,25,26,27,28,30 The Home presents a homely, safe environment and the bedrooms suit the needs and lifestyles of the service users. Bathrooms and toilets are sufficient for the number of service users and all the communal areas maintain the homely atmosphere. All areas of the home seen during the inspection were clean and hygienic. EVIDENCE: One bathroom has been pleasantly refurbished and the lounge which has recently been redecorated, is pleasant, homely. The main shared spaces are well used, especially the dining room where a service user was preparing his breakfast. The bedrooms inspected today reflected the interests, independence and lifestyles of the service users. Each was very individual with their own personal property, colour scheme and treasured possessions. All service users have their own keys. One service user introduced his two goldfish to the inspector. The service users assist with the general housekeeping and the home is clean and hygienic. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 15 Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 The staff teams support the service users with their clear roles and responsibilities. Relevant training, support and supervision benefits the service users. Recruitment practices not only support, but involve the service users and the staff teams help the service users to reach their potential independence. EVIDENCE: The staff teams consist of Team Leaders, Senior Community Support Workers and Community Support Workers who work in three teams during the day and two teams at night. The staff have attended training sessions, as confirmed by talking with staff and recorded in staff files, to address training needs, All staff have a Criminal Records Bureau check and two references prior to starting work. Service users also attend interviews of new staff and put their own questions like “so how can you help me?” This is confirmed by the service user and staff records. The service users spoken with say they feel supported by the staff and that their needs are “being taken care of”. Staff are regularly supervised and training needs identified. The supervision notes now address the feedback from the worker which was introduced following inspection of another unit in the group. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 17 Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41,42,43 The home is well run and the management and ethos of the home has the service user at the core of its approach. The policies, procedures and record keeping protect the service users’ rights and interests. All the relative health and safety areas are carried out as required. EVIDENCE: The home is well run and benefits from the presence of not only the Registered Manager, but also a Regional Manager, or duty manager. The supervision records, care plans and policies all clearly indicate the service user and their rights are safeguarded. Some care plan documentation inspected requiring signatures and date was not signed. Records for health and safety regulations were inspected, including Fire tests and drills, electrical tests, water temperatures, maintenance records and accident book and were found to be recorded and up to date. The management includes Firewardens, at least one on duty for each shift. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 19 Full risk assessments are carried out and recorded in care plans and the home’s documentation and these on inspection, also include regular reviews. Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 2 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 4 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wycar Leys ( The Mews) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 2 3 3 C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 21 None 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 YA15.5 Regulation 12(4)(b) Requirement Service users can develop and maintain intimate personal relationships with people of their choice and information and specialist guidance are provided to help the service user to make appropriate decisions Timescale for action 29/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6.10, YA14.2 YA 15.5 Good Practice Recommendations Care Plan assessments and reviews to be signed by the service users as well as staff members. Reviews to identify activity changes and choices in the individual activities timetables with Activity Manager input as well as Service User input. Care Plans and staff to identify and address differences between what is appropriate and inappropriate expressions of sexual feelings to support service users in such expressions. Staff to ensure all documentation requiring signature and dating has this. 4. YA41.3 Wycar Leys ( The Mews) C53 C03 S48275 Wycar Leys Mews V248047 090905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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