Inspection on 17/10/05 for Wyvern Lodge

This inspection was carried out on 17th October 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 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

Wyvern Lodge 15/03/07

Wyvern Lodge 07/02/06

Wyvern Lodge 03/02/05

Wyvern Lodge 22/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Wyvern Lodge 89 Drove Road Weston Super Mare North Somerset BS23 3NX Lead Inspector Juanita Glass Announced Inspection 17th October 2005 09:30 Wyvern Lodge DS0000020374.V260632.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 Wyvern Lodge DS0000020374.V260632.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. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wyvern Lodge Address 89 Drove Road Weston Super Mare North Somerset BS23 3NX 01934 612416 01934 612416 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) Aspects and Milestones Trust Mrs Elizabeth Anne Hendry Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 8 Adult Patients with Mental Disorder excluding those detained under Mental Health Act 1983 Staffing Notice dated 13/09/1999 applies Manager must be a RN on parts 3 or 13 of the NMC register Date of last inspection 3rd February 2005 Brief Description of the Service: Wyvern Lodge is a community home for people with enduring mental health problems. the home adopts a psycho/social approach, which includes helping service users to maintain and develop independence, well-being and meaningful integration into the community. The home is close to local amenities and a short walk from the main town centre and beach. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place in the presence of the manager Mrs Hendry, the Inspector spoke to four residents and two members of staff, and examined the records for four residents and reviewed staff personnel records. During the inspection residents were observed to come and go freely whilst following their chosen activity, education or work placement. The outcome of this inspection was very positive, one resident who had spoken to the Inspector on two previous inspections was preparing to move into supported housing, he was being supported by staff in obtaining the keys to his flat and purchasing furniture. What the service does well: What has improved since the last inspection? The home has continued to build on its belief that residents can be supported in obtaining meaningful employment and moving on to supported living in the community. Staff morale has improved and staffing levels have been addressed. Residents spoken to who were living at the home before it took on residential status said it had continued to improve, that they had more freedom and say in their future life. Staff supervision records showed a significant improvement. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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 Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, and 4 Prospective service users are provided with appropriate information to make an informed choice about where to live, individual aspirations and needs are assessed prior to admission. Prospective service users are invited to visit the home prior to admission. EVIDENCE: The statement of purpose and service user guide is very concise and easy to read, the homes philosophy included in the guide was discussed and agreed with the service users. The manager discussed the decision to involve the current service user group in re-writing the residents charter so that the group could own it personally. Resident records reviewed showed that all residents had been assessed by the manager prior to admission, they contained copies of the preadmission assessment and copies of hospital or social services assessments. Residents spoken to on the day did not comment on the preadmission process. Prospective residents are encouraged to pay an initial visit to the home to meet the existing residents and staff to discuss their expectations; they are then asked to attend daily and take part in the programme for one week, during which time they are assessed. The decision is then made in consultation with the resident and the current resident group as to whether the home can meet their needs. Staff spoken to said it worked very well and residents had taken a mature approach in agreeing whether a prospective resident would fit in with the current group or not. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 9 Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 10 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 and 8 Service users know their assessed and changing needs are reflected in their individual plans. Service users are assisted to make decisions about their life. Service users participate in all aspects of life in the home. EVIDENCE: During the inspection the plans of care for four residents were reviewed the Auckland tamed a very clear information, all the plans seen showed evidence of residents involvement. They are based on each individuals opinion of their highest need and includes a subjective and objective statement in each, it is acknowledged opinions may differ between the team and the individual but a mutual agreement is met. Any limitations are agreed with the resident, they also agreed to follow the house rules. House meetings are held daily Monday to Thursday and all residents are encouraged to attend. The meetings address the day-to-day running of the home and residents are encouraged to take part in the routine maintenance. As previously stated staff will be looking at using these meetings to review the residents charter with the current resident group. It was evident from care records, talking to staff and to two residents who are currently preparing to move out of the home; that staff had assisted them in making personal decisions and then had enabled them to follow those decisions through. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 11 Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 12 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): 11, 13, 14 and 17 The home provides opportunities for residents to pursue personal development. Residents are encouraged to be part of the local community, and engaged in appropriate leisure activities. Residents are offered a healthy diet and take part in the preparation. EVIDENCE: Progress for residents at Wyvern Lodge centres around personal development. Residents are assisted to attend college, obtain meaningful work and to improve their personal skills around the home. Several of the residents take part in local community projects such as conservation and the park bench project. Staff spoke to confirmed that they had assisted residents in obtaining voluntary work and paid work one resident who works in local so officers is supported by the home to maintain the job another resident enjoys of volunteer work at the helicopter Museum. During the inspection residents were seen coming and going from the home following their chosen activity, education or work placement. Leisure activities are agreed by the residents at the house meetings. A weeks holiday in Newquay was organised for this year, and the home was closed as all went. Other events organised have been a day trip to Torquay, trips to the Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 13 cinema, local events, sporting activities and restaurants. One resident is currently organising a curry and lager night with a quiz as his leaving party. Residents are encouraged to develop personal interests such as music and photography and group work includes art. Staff residents meet twice a year to discuss and agree on a seasonal menu, the final agreed four-week menu is then assessed by diet session for its nutritional value. Slack lunches are generally chosen and cooked by the residents themselves. The home still emphasises healthy eating with fruit being made available after each meal. The home is commended for the way in which it encourages residents to obtain their food hygiene certificates. Residents feel that this is an achievement and are proud of their certificates. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 14 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 and 20 Residents receive personal support in the way they prefer and require. Residents are assisted to retain, administer and control their own medication supported by a very clear risk assessment. EVIDENCE: Residents spoken to felt that the personal support they received was appropriate to their needs and expectations. Two residents who are currently preparing to move out of the home where enthusiastic about the support they had received from staff. Passing comments made by residents were very positive, and they spoke highly of the staff in the home. Residents records showed that personal preferences were taken in to consideration when setting goals with residents. The policy for the receipt, storage and administration of medication includes a very detailed and concise procedure for self-medication, involving a structured risk assessment agreed with the resident. Residents are assessed for competence and progress through stages identified in their care plans; residents received varied levels of observation and support as they progress through the stages. Staff involved in the administration of medication have all received training. One resident currently preparing to leave the home had chosen which stage of risk assessment he wished to remain at until the day he left. This provided him with the support that he had chosen. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 15 Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 16 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): 22 and 23 Residents felt their views were listened to and acted on Residents are protected from abuse, neglect and self harm by the homes policies and procedures, recruitment practice and training. EVIDENCE: Since the last inspection the home has received no complaints, residents are encouraged to raise issues during the house meetings. During one house meeting the residents raised concerns regarding the use of agency staff and lack of continuity of care; a group of letter was composed and sent to the organisations management. Residents spoken to said they could always raise concerns with staff and always felt they would be listened to, one resident said the house meetings were very useful and that would be when he would raise any concerns if he had any. The home has very clear policies and procedures for the protection of vulnerable adults, and for whistleblowing. Training in issues concerning vulnerable adults and adult protection is considered as statutory training within the home, all staff have received training in the local no secrets policy. All new staff assigned to say they have read the aspects and milestones or whistleblowing policy ‘Do the Right Thing.’ All the residents spoken to were aware of the Commission of Social Care Inspection, and knew that they could contact the commission if they wished to discuss an issue. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 17 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): 24, 28 and 30 Residents live in a homely, comfortable and safe environment. Shared spaces compliment and supplement resident individual rooms. The home is clean and hygienic. EVIDENCE: During the inspection the entrance hall and stairwell was being redecorated, residents commented that it was a job that needed doing. Residents and staff work together to maintain a homely and clean environment. Residents rooms are also currently being decorated and residents and staff have been emulsioning walls together using the residents choice of paint or decorating materials. Residents are being encouraged to take part in the health and safety checks around the home. Which residents enjoys taking part in. The is accessible and well maintained, a conservatory continues to be a popular addition and is designated smoking area. The home has a small lounge at the front of house which is a no smoking room, the dining room is at the rear of house and is also used by residents for some of the group sessions such as art therapy and access to the computer. During the inspection the home was as clean and hygienic as can be expected with decorators stripping wallpaper. Staff and residents have a rota of daily and weekly chores. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 36 All staff have job descriptions with clearer roles and responsibilities. A competent, qualified and effective staff team supports residents. The home’s recruitment policy and practice is robust and protects residents from abuse. Staff are well supported and supervised. EVIDENCE: All staff records reviewed during the inspection contained clear job descriptions, staff spoken to confirmed they had job descriptions and had a clear understanding of their roles and responsibilities. Staff rotas confirmed that the home was adequately staffed, a recent recruitment drive means that the use of agency staff is now minimal. This was one concern raised by residents as previously stated, as they felt the use of agency staff meant their care and support lacked continuity. All staff records examined contained the appropriate and required information, this showed that all the appropriate checks were being carried out prior to a new member of staff commencing employment. Aspects and Milestones show a very clear commitment to training and personal development, all staff have attended statutory training and training appropriate to the needs of the current resident group. One staff member stated that they felt adequately supported in obtaining an understanding of the resident group, which was new to them. The Inspector discussed the recording of staff supervision with the manager; the records of staff supervision had improved following the managers return Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 19 from maternity leave, and their continued progress will be monitored at the next inspection. The manager has regular supervision however this is not supported by written evidence. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Residents’ benefit from a well run home with an open and approachable ethos towards management. Residents’ views and opinions are monitored by the home. The implementation of health and safety is satisfactory. EVIDENCE: The registered manager is a qualified registered mental nurse and is currently doing the NVQ 4 Management in Care, she has just been granted an extension of study to March 2006. The management approach is open, positive and inclusive both residents and staff confirmed that they could talk to the manager at any time about any subject. Staff did comment on that they felt they had no direction during the managers maternity leave that things were improving since her return. A satisfaction survey is carried out twice a year when residents views and opinions are taken into account, residents spoken to said they could always put there are views across at the daily community meetings. All the records and policies and procedures required by regulation were up-todate, well maintained and available for inspection. The implementation of health and safety within the home was satisfactory. The manager carries out Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 21 health and safety check monthly and concerns are passed on to the relevant person, residents are also encouraged to take an active part in raising any health and safety issues they may have. The manager is currently looking at including residents on health and safety training. The firelog was examined and provided evidence to support the home carries out the required checks and staff and residents receive training and take part in drills. All service records, evidence of health and safety checks and the COSHH folder were available for inspection All visitors are asked for proof of identity before entering the home and to sign the visitors’ book. Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 4 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 X 3 LIFESTYLES Standard No Score 11 4 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wyvern Lodge Score 3 X 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 3 x DS0000020374.V260632.R01.S.doc Version 5.0 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 Wyvern Lodge DS0000020374.V260632.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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