Care Home: Wells Court

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What the care home does well An assessment of peoples individual needs is carried out before they are offered a place at the home. This is to ensure that people will not be admitted unless the home is confident that their needs can be met. The people we spoke to during the site visit told us that they felt that their care needs were being met. Peoples physical health is monitored and timely arrangements are made for them to receive visits from the professional health care services as and when necessary. The complaints procedure is accessible and the staff have received training to enable them to identify is a resident may be at risk of abuse. The home is spacious, well decorated and comfortably furnished throughout. Mobility aids and appliances are in place which make the home suitable for people who may have physical disabilities.Wells CourtDS0000003852.V375854.R01.S.docVersion 5.2There is a low staff turnover and the staff told us that they work well as a team. Staff are given opportunities to attend training sessions and are helped and to achieve National Vocational Qualifications in Care. The home has achieved an ‘Investors in People Award’. The people who live at the home and their visitors told us that the manager and staff were very good. The registered manager demonstrated that she has a very good understanding of the needs of people who are elderly and that she is able to manage a staff team well. What has improved since the last inspection? The medication administration records have improved considerably since the last inspection. All of the staff have received training on the Protection of Vulnerable Adults. The laundry floor has received attention and now has a hygienic and easy to clean surface. There has been a significant reduction in the staff turnover. The number of staff with or working towards gaining National Vocational Qualifications has increased significantly. Staff now receive regular supervision with their manager. Since the last inspection a new manager has been registered. What the care home could do better: The information contained in the Statement of Purpose and Service Users Guide needs to be kept up to date. Evidence should be provided in the care plans to show how the people who use the service are involved in planning how their individual care needs will be met. The heavily patterned carpets in the communal areas are not appropriate in a home that caters for people with dementia and should be replaced.Wells CourtDS0000003852.V375854.R01.S.docVersion 5.2Additional staff training should be provided on the control of continence and any carpets that smell of urine should be thoroughly cleaned or replaced. The staff administering medicines should be reminded to sign the medication administration record sheets as they see people taking their medication. People should have more opportunities for stimulation available through leisure activities, which are linked to their needs, interests and capacities. All of the residents should be given to opportunity to engage in activities outside their home environment. People should be offered a choice of at least two main course meals at lunchtime. The medication trolleys should not be kept in the residents dining room as they give an otherwise very well presented room an institutional appearance. Suitable locks, the type that can be overridden by the staff in the event of an emergency, should be fitted to all bedroom doors and the residents should be given keys to their rooms. Copies of reports of monthly visits carried out on behalf of the persons in control must be kept at the home and available for inspection. Key inspection report CARE HOMES FOR OLDER PEOPLE Wells Court Herbert Road Salcombe Devon TQ8 8HD Lead Inspector Judy Hill Key Unannounced Inspection 16th June 2009 10:00 DS0000003852.V375854.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wells Court Address Herbert Road Salcombe Devon TQ8 8HD 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) 01548 843484 01548 843484 courtgroup@btinternet.com Wells Court Limited Sharon Rundle Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24), Physical disability over 65 years of age (24) Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 55/65 Date of last inspection 10th June 2008 Brief Description of the Service: Wells Court is a detached property situated in the estuary town of Salcombe in the South Hams area of South Devon. It is registered to provide care for 24 older persons who may also have a physical disability and/or dementia. Accommodation is provided in single bedrooms on three floors. A passenger lift and chair lifts provide access to the upper floors. Most bedrooms have en-suite facilities. There is a spacious lounge, a smaller lounge and a dining room situated on the ground floor. At the front of the building there is a small garden and patio area. Car parking is provided at the rear of the building. Appropriate aids and adaptations are available to assist people. Written information regarding the home and the services provided is available in the reception area and is given to people considering going to live at Wells Court. A copy of the most recent CSCI inspection report was also available in the reception. The current level of weekly fees range from £400 to £450 a week. Extra charges are made for professional hairdressing, chiropody and items of a personal nature. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 star. This means that people who use the service experience good outcomes. This inspection was concluded with a site visit that was carried out by one inspector on 16th June 2009. The information contained in this report was gathered using a variety of methods. Before the site visit we looked at an Annual Quality Assurance Assessment (AQAA) that had been completed for us by the registered manager. We also looked at the last inspection report and information that had been given to us about the service in since the last inspection. During the site visit we spoke with some of the people who live at Wells Court and with three people who were visiting relatives at the home. We also spoke with the registered manager and some of the people who work at the home. Additional information was gained from a tour of the premises and from records, including residents needs assessments and care plans, staff recruitment and training records, medication administration records and menu plans. What the service does well: An assessment of peoples individual needs is carried out before they are offered a place at the home. This is to ensure that people will not be admitted unless the home is confident that their needs can be met. The people we spoke to during the site visit told us that they felt that their care needs were being met. Peoples physical health is monitored and timely arrangements are made for them to receive visits from the professional health care services as and when necessary. The complaints procedure is accessible and the staff have received training to enable them to identify is a resident may be at risk of abuse. The home is spacious, well decorated and comfortably furnished throughout. Mobility aids and appliances are in place which make the home suitable for people who may have physical disabilities. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 6 There is a low staff turnover and the staff told us that they work well as a team. Staff are given opportunities to attend training sessions and are helped and to achieve National Vocational Qualifications in Care. The home has achieved an ‘Investors in People Award’. The people who live at the home and their visitors told us that the manager and staff were very good. The registered manager demonstrated that she has a very good understanding of the needs of people who are elderly and that she is able to manage a staff team well. What has improved since the last inspection? What they could do better: The information contained in the Statement of Purpose and Service Users Guide needs to be kept up to date. Evidence should be provided in the care plans to show how the people who use the service are involved in planning how their individual care needs will be met. The heavily patterned carpets in the communal areas are not appropriate in a home that caters for people with dementia and should be replaced. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 7 Additional staff training should be provided on the control of continence and any carpets that smell of urine should be thoroughly cleaned or replaced. The staff administering medicines should be reminded to sign the medication administration record sheets as they see people taking their medication. People should have more opportunities for stimulation available through leisure activities, which are linked to their needs, interests and capacities. All of the residents should be given to opportunity to engage in activities outside their home environment. People should be offered a choice of at least two main course meals at lunchtime. The medication trolleys should not be kept in the residents dining room as they give an otherwise very well presented room an institutional appearance. Suitable locks, the type that can be overridden by the staff in the event of an emergency, should be fitted to all bedroom doors and the residents should be given keys to their rooms. Copies of reports of monthly visits carried out on behalf of the persons in control must be kept at the home and available for inspection. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People using the service experience good quality outcomes in this area. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the site visit we requested and were given a copy of the Service Users Guide which contains the homes Statement of Purpose. We were also given a copy of The Court Group Retirement Hotels Brochure. The Annual Quality Assurance Assessment that had been completed prior to the site visit told us that these documents are given to prospective residents as part of an Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 10 information pack and copies of the Service Users Guide were seen in some of the bedrooms during the site visit. The Service Users Guide/Statement of Purpose contains a lot of useful information about what the service provided. It does, however, need to be updated. For example, there has been a change of registered manager since this document was published, the name and address of the registration authority, which is now the Care Quality Commission, has changed and more of the staff have completed or are in the process of completing National Vocational Qualifications. The admission procedure, including emergency admissions, is included in the Service Users Guide/Statement of Purpose. This tells us that it is the policy of the home to visit prospective residents in their own home or in hospital to discuss their individual needs with them and their representatives and to carry out an initial needs assessment. The registered manager told us that assessment visits are carried for people who are contracted through Social Services as well as for private residents. Following the managers assessment letters are sent to prospective residents to confirm whether or not the home will be able to meet their assessed needs and copies of these letters were seen on the residents files. If the assessment is positive, people will be offered a place at the home subject to a four week trial period. The trial period is used to enable both the home and the individual resident a further opportunity to make sure that Wells Court can meet the residents needs. During the site visit we asked some of the people who live at Wells Court if they were happy with their choice of home and received only positive comments. We also asked three people who were visiting relatives at the home if they were happy with the care provided and all three told us that they were. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. The care provided is good, but the people who use the service could be more involved in their care plans and reviews. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the site visit we met and spoke with a number of residents. We asked if their care needs were being met and received only positive replies. We looked at the recorded plans of care for two of the people who use the service. Although the care plans and reviews identified the residents needs and how these should be met, they did not provide any evidence, for example signatures, to show us that the people who use the service had been directly involved in drawing up their care plans or consulted on their contents. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 12 The residents health care needs are monitored and referrals are being made to the professional health care services as and when necessary. The Annual Quality Assurance Assessment tells us that six of the people who use the service have dementia. Staffing records showed us that training had been provided in dementia care. We discussed the need to replace the heavily patterned carpets with the registered manager who was aware that these are not suitable for use in a home that cater for people with dementia. Six of the residents were identified in the AQAA as being singly incontinent. Although there were none of the obvious signs of incontinence in the communal areas of the home, some of the bedrooms did smell of urine which indicates that additional advice and training on the control of continence may be needed. Fifteen of the residents were identified as having a physical disability and the home was found to be well equipped with mobility aids. These include a passenger lift, wet rooms, bath aids, hand rails and wide doorways and corridors. The medication is stored in two trolleys which are chained to the wall in the dining room. A controlled drugs cabinet is stored in a locked cupboard and a small fridge is available for storing any medication that my need to be stored in one. The registered manager told us that only trained staff assisted the residents with their medication. We checked the medication administration records thoroughly as this had previously been an area of concern and although most of the records were found to be clear and up to date, the records had not been initialled for one item of medication given on the day of the site visit. During the inspection we observed the interaction between the manager and staff and the residents and found it to be respectful, relaxed and friendly. Some of the residents told us that the manager and staff were kind and helpful and three people who were visiting relatives at the home all told us that the staff were very good. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. More could be done to ensure that peoples social, recreational and occupational needs are met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the site visit we saw most of the residents and spoke with some of them in the lounge and others in their bedrooms. People confirmed that they could use their bedrooms or use the communal rooms whenever they wished. Activities are provided in the large communal lounge and these include games, quizzes and gentle exercise, which are facilitated by the staff as well as organised activities and entertainers who visit the home. The library visits the home to provide books, including large print and audio, for people. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 14 Religious services are held at the home and arrangements will be made to enable the residents to attend church services if they wish to do so. The registered manager said that she has the use of a minibus once a week to take people out but that group outings are not organised that frequently. This is unfortunate as the South Hams is a designated area of outstanding natural beauty and the town and harbour at Salcombe are exceptionally attractive. Some people are taken out by their families, but the staff rarely take people out on a one to one basis. The Statement of Purpose/Services Users Guide tells us that visitors are welcome at any time and this was confirmed by the three visitors who were seen during the site visit. All of them said that they were happy with the care provided at the home and that they were always made welcome when they visited. The Annual Quality Assurance Assessment (AQAA) told us that the people who live at Wells Court have a menu choice each day. During the site visit we asked several people if they had been offered a choice of meals for lunch and were told that they had not. We also asked the residents if they knew what they would be having for lunch that day and none of them knew. One resident told us they were usually offered a choice of meal at tea time but not at lunch time. We discussed the provision of choice with the registered manager and the cook and were shown menu plans which stated that at lunch time the residents had a choice of the set meal, which was scampi and chips, or soup. The options sheet had not been completed and the cook confirmed that the residents had not been offered a choice of meals. To meet this standard the residents must be told that they have a choice of at least two main course meals and what their options are. Feedback from the residents told us that the quality of the meals provided was satisfactory. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 People using the service experience good quality outcomes in this area. The people who use the service have access to the complaints procedure and are protected from the threat of abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Complaints Procedure is included in the homes Statement of Purpose/Service Users Guide. We looked at the record of complaints and only one complaint, which had been dealt with appropriately, has been raised. No complaints have been made to the Commission in the past year but a concern was raised. This was sent to the service provider and deal with it in an appropriate manner. One Safeguarding referral was made in the past year. This was discussed at a multi-disciplinary strategy meeting and no further action was taken. The AQAA tells us that all of the policies, procedures and codes of practice relating to the complaints and the protection of vulnerable adults are kept at the home and are up to date. The two members of staff who were interviewed Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 16 both told us that they had received training on the Protection of Vulnerable Adults. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 People using the service experience good quality outcomes in this area. Wells Court provides a clean, well presented and comfortably furnished home for the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Wells Court is situated in a quiet residential area on the outskirts of Salcombe. Although the town and harbour are less than a mile away, there are very steep hills which would make access without transport difficult for most people. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 18 From the front of the house the home is indistinguishable from any other house in the road, which gives it a very homely first impression. However, the property has been extended at the back to provide additional rooms and car parking facilities for the staff and visitors. There is a small garden to the front of the house which has been attractively landscaped to provide a pleasant seating area for the people who use the service. On the ground floor there is a large lounge, which has been extended by the addition of a sunny garden room. This room is a well decorated and comfortably furnished room and is well used by the residents. A second lounge, which is also comfortably furnished, provides a quieter room for the residents to sit in. The dining room is spacious, well decorated and suitably furnished. However, this room could be made more homely if alternative storage facilities could be found for the medication cabinets. We did note that the carpets in the communal areas were heavily pattered. Although the carpets look to be in good condition and are attractive, consideration should be given to replacing them with plain carpets, which would be more suitable for people with dementia. The registered manager has a small office off the main hallway. This is well positioned as it is easily accessible to residents and visitors to the home. There are adequate communal toilet, bathroom and shower facilities and suitable aids have been provided to enable the people who use the service to access these facilities safely, with help from the staff if necessary. We looked at several of the residents bedrooms and found them to be well decorated and comfortably furnished. Most of the bedrooms have en-suite toilet facilities and those that do not have toilet facilities close by. Although locks have been fitted to most of the bedroom doors, we were told that the residents were not given keys to their rooms. This means that the people cannot lock their bedroom doors from the outside when they are not using their bedrooms. Individual risk assessments had not been carried out to justify people not having keys to their rooms. We did note that a small number of bedrooms smelt of urine and although it is accepted that it can sometimes be difficult to prevent this, consideration should be given to replacing the carpets in the bedrooms that have been affected with carpets that have been designed for use by people who are incontinent. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 19 The laundry facilities were seen to be suitable for the needs of the home. In the last inspection report a requirement was made to render the laundry floor impermeable to reduce the risk of infection and this had been done. Overall we found the premises to be clean, attractively presented and homely. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. The people who live at Wells Court are cared for by well trained and well managed staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment told us that there has not been a high turnover of staff in the past year and this was confirmed by the Registered Manager. We looked at the staff recruitment records and found that safe practices were being used to recruit new staff. We spoke with two care workers in private and both of them said that they enjoyed working at the home. They told us that the staff worked well as a team and that they supported each other in their work. The staff spoken with said that they were provided with good opportunities to attend relevant training, including training on dementia care, and this was confirmed by the staff training records. The staff told us that they received regular one to one Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 21 supervision and attended staff meetings and again this was confirmed through records seen at the home. The home has been proactive in encouraging staff to obtain National Vocational Qualifications at Levels 2 and 3 in Care. During the inspection we met a National Vocational Qualification Assessor who was visiting the home to tell a member of staff that he had achieved his NVQ at Level 3 in Care. The staff rota told us that there are always at least three care assistants and a senior care assistant on duty throughout the day. Overnight cover is provided by one care worker on waking duty and one sleeping in and on call. Very positive feedback was given to us about the staff and the registered manager by the residents we spoke to and by visitors to the home. Wells Court has achieved the Investors in People Award. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. The people who live at Wells Court benefit from living in a well managed home We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection Sharon Rundell has been registered as manager of Wells Court. Sharon told us that she had been employed by the parent Company, which is The Court Group, for many years as a care worker and senior care worker before becoming a manager. She has completed her National Vocational Qualification in Care at Level 4 and is working towards completing her Registered Managers Award. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 23 Throughout the inspection Sharon demonstrated that she has a good understanding of the conditions associated with old age and that she has a good working relationship with the staff, the residents and their families. The Annual Quality Assurance Assessment (AQAA) tells us that regular monthly visits are carried out on behalf of the registered service providers and the registered manager confirmed that these visits were taking place. However, copies of the reports of these visits had not been sent to the home and were not available for inspection during the site visit. The AQAA told us that the Company carry out Health and Safety checks as part of their quality monitoring audit every six months and a report of an audit that had been carried out in March 2009 was seen to confirm this. Questionnaires are used to gain feedback on the quality of the service provided from the residents and regular staff meetings and residents meetings are held to enable the staff and residents to contribute to the development of the service. The staff receive regular one to one supervision with their manager approximately every two months. Supervision records were seen to confirm this. The residents are encouraged to ask their families or a legal representative to help them to manage their financial affairs if they need help. The home will, however, look after small amounts of personal spending money for the residents if asked to do so. Clear and accurate records are kept of any money paid in and money given back to the residents or spent on their behalf. The AQAA tells us that all of the required and recommended policies, procedures and codes of practice are kept at the home and are up to date. Two members of staff confirmed that they knew where the policies, procedures and codes of practice were kept and one said that she had been asked to read some of these as part of her induction training. Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP33 Regulation 26 Requirement Copies of reports of monthly visits carried out on behalf of the persons in control must be kept at the home and available for inspection. Timescale for action 16/08/09 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 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be updated to ensure that the information provided is accurate and up to date. Evidence should be provided in the care plans to show how the people who use the service are involved in planning how their individual care needs will be met. The heavily patterned carpets in the communal areas are not appropriate in a home that caters for people with dementia and should be replaced. 2. OP7 3. OP8 Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 26 4. OP8 Additional staff training should be provided on the control of continence and any carpets that smell of urine should be thoroughly cleaned or replaced. The staff administering medicines should be reminded to sign the medication administration record sheets as they see people taking their medication. All of the residents should be given to opportunity to engage in activities outside their home environment. People should be offered a choice of at least two main course meals at lunchtime. The medication trolleys should not be kept in the residents dining room as they give an otherwise very well presented room an institutional appearance. Suitable locks, the type that can be overridden by the staff in the event of an emergency, should be fitted to all bedroom doors and the residents should be given keys to their rooms. 5. OP9 6. 7. 8. OP13 OP15 OP19 9. OP24 Wells Court DS0000003852.V375854.R01.S.doc Version 5.2 Page 27 Care Quality Commission South West Region Citygate Gallowgate Newcastle uponTyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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