Care Home: Wensley House

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What the care home does well Residents are happy living at Wensley House. The standards of care are sound and the routine of the home is generally residents led. Comments from residents include ‘The staff are looking after me well, I feel better since being here’ and ‘I could not be more at home’. Relatives who commented on the home also speak highly of the services and care provided. The home has a stable staff team who are well trained and know the residents well. The manager supervises and meets with the staff regularly. The staff are also recruited properly. Residents are happy with the food provided and they know how to raise any concerns or complaints should they have them. The home is safe, clean and maintained to a high standard. The management team is committed to continuing to improve the home and services further. What has improved since the last inspection? Wensley HouseDS0000066442.V377769.R01.S.docVersion 5.2Since the last inspection the manager and her team have worked hard to improve standards in the home. A new care planning system is in place and this is supported by a new pre-admission assessment. The management of medication systems has also improved. Improvements have been made in relation to the overall management and supervision of staff in the home and compliance levels for staff training have improved. The new lounge has been completed and the grounds are now secure. Some parts of the garden have been planted to create areas of interest. What the care home could do better: The key area of work for the team at the home relates to the provision of social care and activities. Whilst residents are generally happy with the provision of entertainment/activities, the current programme has a limited scope and does not allow for one to one time. Therefore residents can not always be assured that both their individual and groups needs would be met or that, through social care, their independence, the retention of skills or self worth would be considered. The team at the home need to bring in a therapeutic approach to the provision of social care in addition to residents’ entertainment needs. Key inspection report CARE HOMES FOR OLDER PEOPLE Wensley House Bell Common Epping Essex CM16 4DL Lead Inspector Diane Roberts Key Unannounced Inspection 7th September 2009 09:00 DS0000066442.V377769.R01.S.do c Version 5.3 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. Wensley House DS0000066442.V377769.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 Wensley House DS0000066442.V377769.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wensley House Address Bell Common Epping Essex CM16 4DL 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) 01992 573117 01992 560479 jp.beling@btinternet.com Beling & Co. Ltd Sharon Allison Osborne Care Home 31 Category(ies) of Dementia (31), Mental disorder, excluding registration, with number learning disability or dementia (31), Old age, of places not falling within any other category (31) Wensley House DS0000066442.V377769.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 31 22nd October 2008 2. Date of last inspection Brief Description of the Service: Wensley House is a fully detached two storey building on the outskirts of Epping Town, close to Epping Forest and backing on to Epping Cricket Ground. Nearest shopping facilities are in the town of Epping. Public transport passes close by the home. The home is registered to accommodate thirty-one elderly people (over the age of 65). Accommodation is provided in twenty-one single bedrooms and five shared bedrooms, situated on both floors of the home. Communal space comprises of a conservatory, one dining/sitting room, a further small dining room and one lounge all on the ground floor, there is also a lounge/dining room on the first floor, which is designated as a visitors lounge. Access between floors is provided by a passenger shaft lift. The home is reached by a long private driveway leading to ample visitor car parking to the front of the building. Fully accessible, well maintained, gardens are provided for residents to the front, side and rear of the property. There is a statement of purpose and service users guide available for perspective residents and their relatives to browse through. This is to enable individuals to consider if Wensley house is suitable and can support their specific needs. Wensley House DS0000066442.V377769.R01.S.doc Version 5.2 Page 5 Fees range from £475.00 for a shared room to £700.00 for a single room. Residents do not have to pay for toiletries but do pay for newspapers, chiropody and hairdressing etc. Wensley House DS0000066442.V377769.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The site visit was undertaken over a six-hour period as part of the routine key inspection. The manager was available during the inspection and the proprietor also visited the home. The manager submitted an Annual Quality Assurance Assessment as required prior the site visit. This is a self assessment required by law that details their own assessment of what they think they do well, what could be done better and what needs improving. This information was considered as part of the inspection process and reflected as part of the report. Prior to the site visit, the manager was sent some resident surveys to distribute. Four responses were received. Information received on the surveys is included in this report. On the day it was possible to speak to three residents, one relative and two staff in addition to the management team. A tour of the home was undertaken and a range of records relating to the home and the services offered were reviewed. What the service does well: Residents are happy living at Wensley House. The standards of care are sound and the routine of the home is generally residents led. Comments from residents include ‘The staff are looking after me well, I feel better since being here’ and ‘I could not be more at home’. Relatives who commented on the home also speak highly of the services and care provided. The home has a stable staff team who are well trained and know the residents well. The manager supervises and meets with the staff regularly. The staff are also recruited properly. Residents are happy with the food provided and they know how to raise any concerns or complaints should they have them. The home is safe, clean and maintained to a high standard. The management team is committed to continuing to improve the home and services further. What has improved since the last inspection? Wensley House DS0000066442.V377769.R01.S.doc Version 5.2 Page 7 Since the last inspection the manager and her team have worked hard to improve standards in the home. A new care planning system is in place and this is supported by a new pre-admission assessment. The management of medication systems has also improved. Improvements have been made in relation to the overall management and supervision of staff in the home and compliance levels for staff training have improved. The new lounge has been completed and the grounds are now secure. Some parts of the garden have been planted to create areas of interest. What they could do better: 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. Wensley House DS0000066442.V377769.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 Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to be properly assessed prior to being admitted to the home so they can be sure that their needs would be met. EVIDENCE: A service user guide is available and the manager told us that she is in the process of updating this so it is in a more pictorial format. The guide is available in the main hallway but was not seen to be widely available around the home. The manager has a system in place for assessing potential new residents. Since the last inspection she has updated the documentation and on discussion, only the manager completes these assessments. Two recent preadmission assessments were reviewed. Overall these were sufficiently detailed Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 10 to give a good picture of the person’s needs and the level of support that they would require. There is more person centred information than previously, outlining personal preferences and social history, although this could continue to be developed. The manager needs to ensure that she completes the summary section of the assessment, which outlines whether she feels that the home would be suitable or not for the resident and the assessments should be dated. Further development is needed on the form so that the needs of residents with dementia can be discussed more, for example, how the dementia affects their behaviour, if there is any challenging behaviour and what skills they retain that could be promoted. This was discussed with the manager. The manager in her AQAA said that ‘pre-admission assessments are carried out to ensure we can meet the assessed needs. We invite the service users’ representatives to attend the assessment and we also discuss the service users’ needs with any relevant professionals, to ensure the needs of the individual can be met by the home’. On discussion with new residents’ they said ‘I have settled in well and I really like it here’, ‘I have not seen the service users guide, my family may have it’, ‘I feel comfortable and I had the opportunity to sit and have a good talk with the manager and my family when I arrived’ and ‘I am happy with the move I have made’. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can generally expect to receive the care that they need delivered by staff in the way that they would wish. EVIDENCE: Since the last inspection the manager has tried two new care planning systems, now settling on one. The manager says that the system she has decided upon has a more person centred approach and she is currently transferring the last few care plans over to the new records. The new system is an improvement on the old one that was in place. The care plans are now more individual to the resident and generally they contain more detail on the level of support needed and the preferences and abilities of the residents. They are also written in a way that shows, where possible, that the residents or their relative has had input and in some cases residents had signed the plans. The format of the care plans does however limit the amount Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 12 of information recorded and because of this, in some cases, the information was lacking. For example, some care plans lacked practical direction for staff on how they were going to provide the care and support which they identified as needed and in some cases, residents’ preferences in relation to how they liked to be supported with personal care were also limited. Some care plans, for example on communication, were good and showed an understanding of residents’ verbal communication and use of body language. Overall the residents had the care plans in place that they needed and on discussion with staff and residents, these were a reflection of current need. More attention should be given to care planning for those residents at risk of urinary tract infections and social care plans were weak and are discussed more in Section 3 of this report. It was also noted that the care plans written were not dated or signed which, does not help to evidence how up to date they are. Daily records are written by care staff, but these were seen to be basic and did not reflect the care plan, for example, stating ‘full care given’. Work should be done to develop these notes so they reflect the care plan, the resident as an individual and become a valuable tool when reviewing care plans. The manager in her AQAA says ‘we will try and encourage staff to write more pertinent comments in the daily notes and other relevant records’. The manager has introduced a monitoring form for signs of wellbeing and ill being which is good, especially in relation to the care of people with dementia who have limited communication. However, these are not used consistently and there was no evidence of review or change of scores, so at the current time they are of limited use. This should be reviewed. Residents who commented said ‘the staff are very good when they help you, they are respectful and look after your dignity’, ‘I see my doctor when I want and I see the chiropodist’, ‘the care staff are good with your dignity, I have never found anything embarrassing’ and ‘The staff are looking after me well, I feel much better since being in here’. Staff spoken to knew the residents well and their detailed preferences but admitted to having a limited input to the actual care plan. This should be addressed by the manager to ensure that they are a working document and that the staff have all the information they need about the residents. Relatives who commented said ‘I have not seen my relatives’ care plan for a while now but I do feel involved in their care and discuss their care with the manager’, ‘my relative’s medication has been reviewed recently’, ‘occasionally items in the laundry go amiss’, ‘the staff do encourage my relative to be independent as much as possible’, ‘the staff know the residents well’, ‘if my relative needs any medical attention, this is dealt with promptly’ and ‘I never worry about my relative as I am confident that they are well cared for’. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 13 Residents had a range of risk assessments in place that covered, for example, manual handling, use of bed rails, falls, risk of pressure sores etc. Where risks have been identified, for example with pressure sores, the management of the risk should be clear and if required always linked to a care plan. In general the risk assessments were up to date although this still requires some work as some were noted to be last reviewed in April 2009. There is evidence in the records that residents are now being weighed regularly and the manager showed us the new nutritional assessments that she was just completing for each resident, which will form part of the care plan. These included residents preferences, dietary needs etc and a risk assessment from the local dietetic service. Records show that residents have seen the dietician where there have been any concerns. Records also show that residents have access to external healthcare professionals such as doctors, chiropodists, physiotherapists etc. and residents spoken to confirm this. The medication system was reviewed and found to be managed well, with good recording of medications coming into and out of the home and those administered to residents. The manager has a self auditing system in place. At the time of our visit she was planning to switch the supplying pharmacist and this would enable her to use a different auditing tool, with the pharmacist who would audit with her in future. Controlled medications are stored correctly and good records are maintained. It is recommended that the manager develops a recording system for those residents taking Warfarin, whose dose may alter in line with blood test results, so staff are clear of the dose to be given. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 14 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): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to have choice in their daily lives and to receive a good meals service; however limitations in social care and activities may mean that their expectations are not met or their needs fulfilled. EVIDENCE: From the records and discussion with residents and staff, it is clear that the routines of the day are generally resident led. Staff speak about residents in a person centred way and identify their rights and choices. Residents spoken to said ‘I have choice about how I spend my time and where I spend it, I also choose when I want to go to bed and get up’ and ‘I choose how to spend my time and go to bed when I want to go to bed’. Social care plans, whilst in place, were weak and gave no real assessment of residents’ social care needs. Care plans gave general statements such as ‘bed rest’ or ‘promote social stimulation’ and listed residents’ interests. There was Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 15 no plan of action in place that would help to promote residents’ independence, self worth or the retention of skills. Where the plan identified that the resident had limited abilities, there were no suggestions as to what interaction could be provide to the resident. This was discussed with the manager. Some residents also had limited social and family history information in place, which in a home that cares for people with dementia is especially important to help staff appreciate residents as individuals. This aspect of information gathering could be developed further to find out more about the person. The manager has not been successful in recruiting an activities officer and at the current time this responsibility lies wholly with the care staff. Where there are specific needs, some of these have been met, for example, finding people to provide one to one time so residents can go out. Staff spoken to say that some activities, like external entertainers are arranged and ‘sometimes we get out the scrabble or some old photos’. Overall the provision is limited, quite repetitive and not always organised. Records show that residents have, sat in the garden, listened to another resident play the piano, outside entertainer and exercise classes. Church services are also held at the home. From the programme and the records seen, whilst group entertainment needs may be being met, individual needs are not fully assessed or planned for. For example, there is no one to one time programmed into the monthly activities. Residents who commented on the activities provided said ‘there is a music man who comes in – I don’t really like it’, ‘I would like to go out more’, ‘I do go out with a friend to play bingo’, ‘I like the singing and the activities, there is usually something different most days’, ‘it would be nice if we had more days where we are all entertained, especially at the weekends’, ‘I don’t see the care staff really doing any activities’, ‘there is a programme but the majority of what’s’ on it is not for me’ and ‘there is a man who comes and does exercises who is good’. The manager in her AQAA said ‘There is an activities programme planned ahead for each month. We try to have a person centred approach to activities recognising that everyone has there own preferences’. We would not fully concur with this statement. On areas for improvement the manager said ‘we look to improve upon our activities programme by having more varied activities on offer’. Lunch was observed and the tables were nicely laid with condiments available. Plastic beakers are used for drinks and consideration should be given to using more age appropriate glasses. Residents were observed to be enjoying their lunch, which looked appetising. Staff were seen and heard to offer residents choices and alternatives from the menu. Residents who commented on the food provided in the home said ‘the food is quite nice, there is a choice of two meals, yesterday we had roast pork – it was very nice’, ‘the choice of food is up on the board and staff come and ask you what you would like’, ‘last night they made me egg on toast as I did not want sandwiches’, ‘there is a choice of cereal at breakfast and sometimes we have Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 16 bacon sandwiches, there are no pots of tea on the tables’, ‘the food is good, you cannot grumble, its varied and you get a choice’ and ‘sometimes there is cake and fruit is available’. Relatives who commented said that ‘the food always looks good’, ‘my relative likes fruit and its available with breakfast’, Some residents were seen with drinks other than during the tea or coffee rounds but this was not widespread. On discussion with the manager, this practice was in place because of the behaviour of one resident, who may pour out the drinks. This needs to be reviewed and managed so that the behaviour of one resident does not potentially adversely affect the rest of the residents in the home. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 17 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can expect to have their concerns listened to and dealt with appropriately and be protected, as far as possible, by the staff training and adult protection systems in the home. EVIDENCE: The manager has a complaints procedure in place which is displayed in the main hallway. This requires review to bring it up to date and consideration should also be given to the format for the resident group. Since the last inspection the manager has not received any formal complaints. The manager has yet to start recording verbal concerns and this was discussed as a point of good practice as they can help with aspects of quality assurance and sometimes identify, on review, patterns of concern. It also helps to evidence an open approach to the management of complaints. The manager said that she has had odd concerns over the laundry and in the future would record these. Residents who commented said ‘if I had any concerns I would phone my family and they would raise it. I would be quite confident that any concerns would be addressed’ and ‘the manager is often about and always asks if I am ok or if I want to know anything, I am quite satisfied’. All of the residents and relatives who commented on our surveys said that they knew how to raise a complaint. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 18 Minutes of the residents meetings also show that residents are informed on how to raise any concerns or complaints. On discussion with staff, they showed an understanding of adult protection matters and the manager has the local guidance available. The training records show that all the staff have up to date training in adult safeguarding. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 19 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, clean and well maintained home. EVIDENCE: A tour of the home was undertaken with the manager. All of the communal areas were visited along with bathrooms and several bedrooms on both floors. Overall the home was seen to be very clean, safe and well maintained. Residents had personalised their rooms and brought in small items of their own furniture. Some residents had their own double beds. There is ongoing evidence of regular bedroom redecoration as this was observed and following consultation with residents, the manager told us that locks for all bedrooms doors were on order. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 20 Residents spoken to were happy with the facilities in the home and comments included ‘I am happy with my room and the maintenance man is good, he comes and fixes anything’. Relatives who commented said ‘the home is clean and it never smells’, The manager told us that they plan to replace the dining room carpet in the near future, following a flood where the carpet was damaged. Signage around the home is limited. On discussion with the manager, she said that they were just in the process of updating the signs and these would be reinstated in the near future. This is especially important in a home registered to care for people with dementia. Since the last inspection the grounds have been made fully secure, so that residents can wander outside if they wish and residents were observed to be taking this opportunity. Paths run around the garden and a rockery/flower bed has been made for interest. Garden furniture is also available. The new lounge has also been completed and is in use. It has a very different atmosphere from the oak panelled lounge and this needs to be reviewed to encourage more residents to use it as the majority still all sit in the old lounge. A more homely atmosphere is needed with possibly some pieces of furniture other than just chairs. Records in relation to fire safety were reviewed and generally found to be in good order with tests and maintenance of equipment up to date. The fire safety risk assessment was recently out of date and requires a review and whilst staff were having fire drills, these could be more frequent with the last drill being January 2009. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 21 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are cared for by a stable and well trained staff team. EVIDENCE: At the current time the staffing levels are 4 plus the manager in the mornings, 4 in the afternoon and evenings and 2 at night. In addition to this there is always a person on call at nights. In relation to the dependency of residents, it may be of value to review the staffing provision for late evening and early morning to support the night staff as quite a few residents go to bed late and choose to get up early. Residents who commented said ‘the staff come promptly if you call them’, ‘The staff are nice people – day and night’, ‘the night staff are busy and have a lot to do in the morning’, ‘the staff do chat to you and if you want anything they will get it for you’, ‘the staff come quickly if you call them, its no trouble at all’ and ‘the staff are all quite nice, you cannot grumble at them at all’. Relatives who commented said ‘the staff are approachable’, ‘Communication from the staff is good’, ‘the home and staffing levels are no different at the weekends’, Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 22 Records show that 84 of the staff have achieved an NVQ 2 or 3 qualification. Training records show that some staff are also in the process of completing these courses. Staff files were reviewed in order to check the robustness of the recruitment procedures in the home. 2 files were checked at random and found to be in good order with all the required checks and documentation in place. On the interview records, the manager needs to evidence that she has explored any gaps in employment. Training records show that the manager undertakes a lot of the training in the home and has completed training herself to undertake this role. Compliance with training for the majority of subjects, such as manual handling, infection control, dementia, fire etc are very good. In addition to the statutory subjects, some staff have attended training on oral care, nutrition and skin care. Consideration should be given to providing training to staff on conditions associated with old age, such as diabetes etc. Records on staff files also show that they are completing inductions to the home in an appropriate way and where required are undertaking the Skills for Care induction course. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 23 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. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well run home where they are consulted about issues that may affect them. EVIDENCE: Since the last inspection the manager at the home has been registered with the CQC. The manager is experienced and has held managerial posts in other care homes. She has completed the registered manager’s award and have NVQ levels 2 and 3 in care management. The staff spoke highly of the manager and said that she was approachable and had ‘an open door policy’. They also confirmed that they attended staff Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 24 meetings and minutes show that these are open forums and good practice is promoted. The manager has a quality assurance system in place that primarily consists of a feedback questionnaire for residents and relatives. This was completed last year but the manager got a limited response. At the time of our inspection the questionnaires had just been sent out with only 2 returned. These showed that so far the responses were very positive. On completion the manager plans to develop an action plan to address any points raised. In addition to questionnaires, the manager meets with residents every couple of months and the minutes show that residents are consulted about services I the home and their opinion is sort. Residents who commented said ‘I am very happy being here in this home’, ‘I really like it here’ and ‘I could not be more at home’. Relatives who commented said ‘the home is so much better now, there are more meetings, activities and a key worker system’, ‘I am pleased to have my relative in such a lovely home’, ‘an excellent home, highly recommended’, ‘the home is friendly and caring and the staff do all they can to make the residents feel comfortable’, The manager does not take responsibility for any residents’ finances and relatives are encouraged to take on this role. The manager has set up a staff supervision system. At the current time she undertakes all the staff supervision but is training the deputy manager to also take on this responsibility. Records show that staff are receiving supervision every 2 months. In her AQAA the manager said ‘we are now carrying out regular supervisions on all care staff; this has helped to enhance staff performance and personal development’. Accident records were reviewed and these are completed well and where needed, records show that residents who have had regular falls are referred to the falls prevention team and measures are put in place to reduce risks. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 25 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 n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 3 X 3 3 X 3 Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 26 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 OP12 Standard Regulation 16 Requirement Following an assessment of residents’ needs, develop a social activity programme that meets those needs in both and individual and group way. Timescale for action 31/12/09 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 OP1 2 OP3 3 OP16 Refer to Standard Good Practice Recommendations Ensure that systems are in place that enables all residents to have easy access to the service users guide. Develop the dementia aspect of the pre-admission assessment documentation. Make a record of all complaints and concerns, including minor verbal ones, to help ensure issues are addressed fully and patterns reviewed. Wensley House DS0000066442.V377769.R01.S.doc Version 5.3 Page 27 Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne 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. 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. 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