Inspection on 07/02/06 for Wyvern Lodge

This inspection was carried out on 7th February 2006.

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 17/10/05

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 Unannounced Inspection 7th February 2006 09:30 Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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.V287748.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 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.V287748.R01.S.doc Version 5.1 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) admin@aspectsandmilestones.org.uk 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.V287748.R01.S.doc Version 5.1 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 17th October 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.V287748.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a very relaxed and positive inspection; the future of the service provided by the home was discussed. Residents have embarked on a property management scheme within the company to provide meaningful development in an employed setting. Residents spoken to were very positive about the care and support provided by staff at Wyvern Lodge. No requirements were made however two recommendations were discussed with the manager. What the service does well: What has improved since the last inspection? What they could do better: Two recommendations were made at this inspection a few handwritten MAR sheets had not been signed by staff and the complaints procedure although readily available for residents still had the Aztec West address. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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.V287748.R01.S.doc Version 5.1 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, 4 and 5 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 and they are offered the chance to visit the home. Each service user has a signed contract or statement of terms and conditions. EVIDENCE: The home continues to have a clear and concise statement of purpose and service user guide it has not been reviewed since the last inspection. They both contain enough information for service users to make an informed decision. Service user records reviewed showed that the manager assesses all prospective residents and then offers them a chance to visit the home for a week so that a full assessment can be made, this visit involves the prospective resident taking part in the homes activities and community meetings. Current residents also have a final say about the suitability of the prospective resident. One resident spoken to on the day confirmed that the week long visit and information from both staff and residents had been very important in him reaching his decision whether to take a placement at Wyvern Lodge. All residents have a signed contract or statement of terms and conditions with the home the also agree to the home rules. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8 and 10 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. Service users information is stored appropriately and both staff and residents are aware of the need for confidentiality. EVIDENCE: The care plans for five residents were reviewed they contained very clear information for staff all the plans showed evidence of residents involvement. They are based on each individuals perceived opinion of their needs, they include a subjective and objective statement in each, both staff and residents acknowledge that opinions may differ between the team and the individual but a mutual agreement is met. Any limitations imposed are agreed with the residents and on admission they agree to the house rules; these have been set and agreed by current residents. Community house meetings are held Monday to Thursday and the daily running of the home is discussed during this time, residents spoken to said they found the meetings helpful and the minutes, which are kept by the Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 10 residents, showed that they considered all aspects of running the home from maintenance needs to leisure activities. Since the last inspection two long standing residents had been assisted with moving on, one into his own flat with support from staff and another to a placement closer to his family. Residents spoken to said that it was really encouraging to see other residents make decisions about their life and the home supporting them in attaining their goal, one residents said it gave them something to work to. All records are stored securely and both staff and residents are well informed of the importance of observing confidentiality. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 14, 15, 16 and 17 The home provides opportunities for residents to pursue personal development. Residents are encouraged to be part of the local community, and engage in appropriate leisure activities. Residents rights are respected in everyday life. Residents are offered a healthy diet and take part in the preparation. EVIDENCE: The home continues to encourage and support residents in maintaining personal development with courses at the college and training centres and part time jobs, or voluntary posts to enable them to return to the working world. Staff also support residents in the home to improve personal skills such as cooking and maintaining a budget. Staff and residents spoken to confirmed that residents do hold down jobs and voluntary work, and the manager confirmed that they were in the process of starting a business with the residents in property management within the organisation, this will be agreed within benefit constraints and will give those residents who cannot obtain work a working experience. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 12 Leisure activities continue to be agreed by the residents in house meetings and the minutes showed evidence of discussions in this area. The home provided a week’s holiday in Newquay last year when the home was closed as everybody went. At the time of the inspection they were looking at the possibility of a spring holiday, and they were planning a trip to Stratford on Avon to see a play. Residents are discussing speakers that they would like to invite to their meetings. During the inspection residents were observed to be coming and going at will to their various groups or jobs. Residents spoken to said that they felt their rights were respected by staff and other residents in the home. The meals provided in the home continue to be commendable, Staff and residents meet twice a year to discuss and agree on a seasonal menu; the four-week menu is then assessed by a dietician for its nutritional value. Snack 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.V287748.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents receive personal support in the way they prefer this includes both physical and emotional support Residents are assisted to retain, administer and record their own medication, supported by a clear risk assessment. EVIDENCE: Residents spoken to felt the care they received was what they required and expected, they felt the emphasis was on support to move on and liked the feeling that they were not at Wyvern Lodge for life, one resident said care was not the right word, rather support and trust. Residents records showed that personal preferences were taken into consideration when care plans were written, they also showed evidence of both physical and emotional needs being taken into consideration. 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. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 14 Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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 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. Residents spoken to said they could always raise concerns with staff and always felt they would be listened to. The home has very clear policies and procedures for the protection of vulnerable adults, and for whistle blowing. 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 sign to say they have read the Aspects and Milestones whistle blowing 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.V287748.R01.S.doc Version 5.1 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 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: A tour of the premises was not carried out during this inspection, however their was clear evidence of on going maintenance and repair, the hallway and stairs had been decorated since the last inspection and staff and residents were doing individual rooms. A conservatory continues to be a popular addition to the building and is the 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. A high standard of cleaning is maintained, both staff and residents have a rota of daily and weekly chores. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 17 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): 32, 34, 35 and 36 Residents are supported by competent and qualified staff. Residents are protected by the home recruitment procedure. Staff are appropriately trained and receive regular supervision. EVIDENCE: Staff rotas confirmed that the home was adequately staffed, the manager confirmed that there was very little use of agency staff providing continuity for the residents. 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. Staff spoken to felt adequately supported with both training and supervision. Staff records showed evidence of regular supervision, which is used to identify training and personal development. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 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 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, 40 and 42 Residents’ benefit from a well run home with an open and approachable ethos towards management. Residents best interests are protected by the homes policies and procedures. 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 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. 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 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 firelog was examined and Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 19 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.V287748.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 3 4 4 5 X 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 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 X 3 LIFESTYLES Standard No Score 11 4 12 X 13 X 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 X 3 X 3 X Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 21 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. 1 2 Refer to Standard YA20 YA22 Good Practice Recommendations Handwritten MAR sheets need to be signed by the person making the entry. The complaints procedure needs to include the current CSCI address. Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Wyvern Lodge DS0000020374.V287748.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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