Care Home: Wetley Manor Residential Care Home Limited

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What the care home does well The home is very well presented to people wishing to move into the home, both in general appearance and in the excellent sources of information provided. The assessment of needs and derived care plans achieve very good outcomes for the people using the service and are delivered in an individual way and as the people wish by well-trained, competent and caring staff. Staff appear friendly and sensitive in their dealings with people using the service who in conversations with us, were very complementary. The home delivers safe services such as medication administration, a safe and healthy environment and has adult protection as a priority. People who use the service are particularly pleased with the high standard of the meals and find the gardens and views a source of pleasure. Individual bedrooms are comfortable, furnished and decorated to people`s personal choice and with many personal possessions. The allocation of well-trained staff is appropriate to the needs of the current people using the service and staff demonstrate the skills necessary to meet their needs. What has improved since the last inspection? The home has been proactive in addressing the diverse needs of the people using the service. The assessment of, and derived plans to address theseneeds are detailed and clearly documented. Staff demonstrate an awareness of these needs. The recruitment process has been improved to ensure all references and checks are complete prior to appointees commencing. The conservatory has been refurbished and provides an additional quality communal facility. The rewiring programme has been completed. A quality assurance system has been introduced and the views of people using the service sought on all aspects of the service with positive findings. What the care home could do better: The home has an informative and up to date Service User Guide, however it needs to include information specifically about fees and a system established so that personal copies are available to the people using the service. This will ensure that people are able to make informed choices. People need to be aware that supper available and the time of service. While it is clear that alternative meal choices are available and a number of people confirmed this, an alternative choices menu should be developed. Sufficient staff should be trained to NVQ level 2 standard to ensure that the 50% standard can be maintained even during periods of staff leaving the service. This will give people using the service confidence that they are supported at all times by appropriately trained personnel. The quality assurance processes should be extended to include seeking the views of families and visiting professionals such as GP`s and community nurses. This will provide the home with a more comprehensive view of their service and aid improvement. CARE HOMES FOR OLDER PEOPLE Wetley Manor Residential Care Home Limited Abbey Road Wetley Rocks Stoke On Trent Staffordshire ST9 0AS Lead Inspector Richard Eaves Key Unannounced Inspection 24th September 2008 09:30 X10015.doc Version 1.40 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 Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 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 Older People. 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. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wetley Manor Residential Care Home Limited Address Abbey Road Wetley Rocks Stoke On Trent Staffordshire ST9 0AS 01782 551144 01782 551144 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) Wetley Manor Residential Care Home Limited Mrs Dianne Barbara Rushton Care Home 22 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (22), Physical disability (2), Physical disability over 65 years of age (8) Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD - 2 beds minimum age 55 years and over. Date of last inspection 3rd October 2006 Brief Description of the Service: Wetley Manor Residential Care Home is a care home providing personal care and accommodation for up to 22 people. The home is privately owned by Wetley Manor Care Homes Limited. The home is located in the rural village of Wetley Rocks, Staffordshire and is accessed from the road via a long driveway. Amenities can be reached by transport but are not within walking distance. The home is laid out on one level and has 20 single and one double bedroom all with en suite facilities. There are five communal rooms including a conservatory and sun lounge area, and a separate dining room. The grounds are spacious, attractive and accessible to the people using the service. Views from the home are of the surrounding countryside and there is a car parking area at the entrance to the home. Range of fees: £388 - £402 per week. The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the Home. Wetley Manor Residential Care Home Limited DS0000005033.V372168.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 3 stars. This means the people who use this service experience excellent quality outcomes. This key unannounced inspection visit was undertaken by an Inspector from the Commission for Social Care Inspection, over one day using the following information: reports from the organisation relating to the conduct of the home, records maintained at the home, the Annual Quality Assurance Assessment and reports by other agencies. The inspection involved a full tour of the property including, a number of bedrooms, the communal rooms and service areas and provided an opportunity to speak with many of the people using the service. What the service does well: What has improved since the last inspection? The home has been proactive in addressing the diverse needs of the people using the service. The assessment of, and derived plans to address these Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 6 needs are detailed and clearly documented. Staff demonstrate an awareness of these needs. The recruitment process has been improved to ensure all references and checks are complete prior to appointees commencing. The conservatory has been refurbished and provides an additional quality communal facility. The rewiring programme has been completed. A quality assurance system has been introduced and the views of people using the service sought on all aspects of the service with positive findings. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 7 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 Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with good sources of information, although this should include the fees to help them make informed choices. People wishing to move into the home can be confident that the home can meet their needs and they are invited to visit the home before making a decision. EVIDENCE: The home’s Statement of Purpose and Service Users Guide are kept under review and they are very good sources of information for current and prospective people using the service and their families. We found that the guide was available in the reception area but not in individual bedrooms as the Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 9 original issue is given before admission and usually retained by the family. The Service User Guide includes the complaints procedure and comments received in surveys undertaken of the views of people using the service and their visitors, but it does not include information about the range of fees. We selected three people’s files to check, (we call this case tracking) and we saw a copy of the contract/terms and conditions in each and a letter confirming that the home can meet their needs following assessment. We saw that assessments are undertaken before admission by the care manager and a sample were viewed as part of case tracking, as well as two more to ensure consistency. The assessment process in each of the files inspected was thoroughly completed and informative and consisted of an ‘activities of daily living’ model and a range of risk assessments for nutrition, pressure areas, falls, manual handling, social, mental health and specific risks. Diversity is included within the assessment process and for the current people using the service includes gender, ethnicity and spiritual wishes. The most recently arrived person who uses the service said that the home accommodates his wishes to take communion and that they also provide a place where smoking is allowed, which was not found in other homes considered. His preference is to smoke outside if the weather allows. He found his assessment to be thorough and address all his needs and wishes. It was confirmed that he had visited the home as a part of his assessment and had viewed the room now occupied. An older person using the service expressed the view that while being of a “religious sort” actively chose to action this through quiet time and personal prayer. A lady of mainland European origin said that her needs are met and that the home helps her to maintain family contacts and also to source video tapes in her first language. The home does not provide an intermediate care service. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home meets the health and personal care needs of the people using the service with detailed assessments and care planning, respect and privacy and access to health care. Medications are well managed, facilitating the promotion of people’s health. EVIDENCE: Care planning drawn from the comprehensive assessments, is well organised, current, clearly written and comprehensively encompasses the range of ‘care areas’ necessary to ensure the delivery of care appropriate to the general needs of each person. Diversity needs are addressed, these currently include spiritual, ethnicity and gender and clear guidance is provided for staff to meet specific individual Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 11 needs, such as religious services including communion, while ensuing staff know not to invite one person of Humanist persuasion. A lady of European origin said she is very happy, that the home helps her to maintain contact with her sister by telephone and that they have sourced videos in her first language. All people using the service are registered with a local G.P. and records show that there are regular visits from other health professionals such as Chiropodist, Dentist, Optician and District Nurse. People using the service are assessed by senior staff in such areas as pressure relief and continence equipment and referred as required for professional advice and supply. Nutrition and falls are risk assessed and necessary interventions and monitoring arrangements are in place including, meals intake, weight monitoring and plans to minimise the risk of falls. Overall the dependency levels at the home are low to medium but all are addressed thoroughly and undertaken sensitively at the pace of choice by the people using the service. The largest proportion of medicines are administered from a monitored dosage cassette system. All people using the service are assessed for selfadministration but each has requested that staff undertake this on their behalf. Each file includes a summary of medication and evidences the reviews undertaken by the GP. Staff involved with medication administration have received accredited training We saw that the ‘booking in’ and returns records are well kept and the Pharmacist provides advice and independent audits quarterly. The procedures for medication are available with the medication administration records (MAR). Facility for receipt and storage of controlled drugs are available but none are currently in use at the home. Since the last inspection a dedicated medication fridge has been obtained and is located in the medication store. The MAR charts are fronted by a photograph of the person and essential information, such as allergies completed. The MAR charts are completed thoroughly and appropriate omissions fully documented. In conversation with people using the service they all expressed satisfaction with the home and in addition to the pleasant location and lovely meals, a large part of the satisfaction is derived from the sensitive involvement of the staff who ensure they have free choice and respect their privacy. They said that their clothes are looked after and help them to maintain a good appearance. Over the day staff were observed to interact with respect, knocking doors before entering and checking individual wishes such as, “Would you like to come to the dining room for lunch?” Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 12 The self-audit identifies whether examinations and treatments are to be undertaken in the person’s own room. A cordless phone is available for use if the person is not in possession of their own, which many are. The topic of respect is given a high profile during the staff induction programme. Terms of address are identified and staff spoken with said they know of each person’s preference, particularly where diminutives are used and one person for whom this is important confirmed that staff know of his wishes. The wishes of persons using the service in the event of their death and dying are recorded early in the settling in period, but with consideration given to the person’s feelings and those of the wider family where appropriate. Wetley Manor Residential Care Home Limited DS0000005033.V372168.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a varied social and recreational activity programme that provides interest and pleasure for the people using the service. The involvement of family and friends is encouraged and people using the service are supported and encouraged to exercise choice in their lives. Meals at the home are wholesome and meet the nutritional and personal needs of the people using the service. EVIDENCE: The home has an activities programme, which is displayed on the notice board and is flexible in implementation according to the wishes of those who want to participate. The home employs an activity assistant for two 3-hour sessions to provide the structure and organisation for ‘in-house’ events. Life histories form an important insight into people’s wishes and help ensure they will be included in practice. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 14 The ‘in-house’ activities include, acknowledgment of birthdays, interactive gardening with a visiting gardener who also does video shows about the countryside. Entertainers visit regularly for singing and ‘movement to music’ is a regular weekly event. The activity assistant leads craft sessions, which include preparing calendars, decorating hats and making bookmarks. People using the service told us that they enjoy activities such as bingo, particularly a form of this called ‘nostalgia’. Other in-house events that give pleasure are reminiscence sessions, group newspaper sessions and general group chats. Recently a clothes sale was provided at the home and the ladies said they enjoyed that. Regular church services at the home are very popular with most people at the home and the home identifies special wishes and respects these. The activity assistant leads the process of planning for such times as Christmas and other themed opportunities. The small shop within the home is stocked with items requested by the people using the service who make use of it. It has been developed overtime to provide a range of toiletry items, tissues and sweets. The library is well stocked with the library service changing the books regularly. Away from the home a small number of outings are arranged during the summer and evening trips to the theatre have been organised. A number of the people using the service said that they have been out shopping with family and had meals out. The home identifies that they actively encourage close family involvement and most people at the home receive very good support and regular visits from family and friends. Families have indicated in previous surveys that they can visit at any reasonable time and feel that the staff are welcoming. The finances of people using the service are either maintained by them or their families. The home provides for assisting with personal allowances where this is requested and good records and auditing arrangements are in place for this. Details of advocacy services are available on the notice board and people spoken with said they were aware that they could look at their personal records if they wished. On touring the building and speaking with the occupants of rooms it was clear that the home accommodates extensive agreement to personal possessions being brought in. Meals at the home are very well received and delivered in a very pleasant setting, domestic in appearance with recently replaced furniture, which people said added to the dining experience. The home received a good report on catering from the Environment Agency. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 15 The home has a three-week rotating menu, but this does not include choice. In conversation people said they know they can choose alternatives. One lady said that she didn’t like pork and she was always offered a choice of alternatives when pork was on the menu. Breakfast consists of a variety of choices including a cooked option. Lunch is the main cooked meal, while tea is served between 5 and 6 o’clock consisting of a sandwich and/or light cooked options. Supper is served from 8 o’clock and is sandwiches, biscuits and milky drinks; this service is not currently shown either on the menus or the Service User Guide. The home should make sure that everyone knows that supper is available. During this visit, we found Lunch to be a very enjoyable meal, nicely cooked and presented and nutritious in content. The meal was relaxed and everyone appeared to enjoy it, the staff were attentive throughout and gave assistance where required. A range of dietary needs can be provided for and fresh fruit and vegetables are used and available. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 - 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service and their supporters can be confident that their views will be listened to and acted upon. Staff are taught how to uphold the welfare of the people using the service and to protect their rights. EVIDENCE: The home has a complaints procedure that is included in the Service User Guide and promoted widely including notices throughout the home. The procedure provides for timely response, investigation and recording of the outcomes of any complaints. The home has not received any complaints over the past year. The AQAA identifies an ‘open door’ approach to the running of the home. People spoken with said they know whom to approach if they have concerns and worries. The lack of an individual copy of the Service User Guide may mean that concerns are not addressed effectively. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 17 The home completes the electoral roll annually and most people elect to use postal votes. The notice board near the home entrance includes details of advocacy services in the local area. The home has policies and procedures in place to protect the people using the service from abuse, and a ‘whistle blowing’ policy. They also have a copy of the local multi agency policy for responding to abuse, and the Department of Health ‘No Secrets’ document. Staff have all received training in the Protection Of Vulnerable Adults, although recent appointments have as yet only received in-house training as part of their induction. The staff we spoke to said they know what constitutes abuse and are confident that they would respond to any signs that they may observe. There have not been any safeguarding referrals during the past year. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use the service live in a comfortable home that offers them a life style suited to their age and condition. Specialist equipment, consistent with the needs of the people at the home is available to facilitate the provision of care. EVIDENCE: The home is located in the countryside on the edge of Wetley Rocks and provides exceptional views. Access to community resources is facilitated by transport because the access drive is rather long to walk for public transport. This fact has an impact on people and staff when deciding to live or work at the home. A local hire company has a range of disabled accessible vehicles. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 19 The gardens are attractively maintained with several seating areas provided, a greenhouse, bird tables and other points of interests for people to enjoy. Since the previous inspection two further patio areas have been developed The home is well maintained with a rolling programme of decoration and refurbishment including the exterior completed this year. A rewiring programme has recently been completed and the conservatory fully refurbished, adding a pleasant addition to the communal areas. The home provides comfortable all ground floor accommodation with single ensuite bedrooms. One registered double is used exclusively as a single. During the tour of the building we visited a number of people in their rooms and they happily showed how they had personalised their rooms with examples shown of their hobbies and interests. The home has numerous communal rooms with comfortable lounges and a separate dining room. These rooms are all pleasantly decorated and lit in domestic character. A small room is available for smoking, this room is also used by the hairdresser with the agreement of the smokers who either choose to smoke outside or suspend smoking to the part of the day a week that the hairdresser visits. Bathrooms and communal lavatories are fitted with necessary aids, adaptations and equipment for ease of use by people using the service. Future development could include communication aids such as a loop system. Heating and lighting meets standards for safety and comfort and hot water is delivered at a safe temperature and regularly monitored. The home is clean, hygienic and free from odours and staff receive training in infection control. The kitchen and laundry are fitted with commercial standard equipment and fittings Wetley Manor Residential Care Home Limited DS0000005033.V372168.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 – 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are clear as to their individual roles and responsibilities and are enthusiastic, sufficient in numbers, well trained and committed to maximising the quality of lives of the people using the service. The recruitment practices and staff training contribute to ensuring people using the service benefit from the skills and knowledge of the people supporting them. EVIDENCE: Staff rotas were inspected and show that two care staff are allocated as a minimum across the 24-hour day with an additional carer during the morning between 8am and 11 am and the manager in addition to these numbers. An activity assistant provides two 3-hour sessions and the proprietor undertakes much of the maintenance. A full range of ancillary staff support care in the kitchen and housekeeping. Staff are happy that this is adequate to meet current dependency needs of the people using the service. Currently 7 of the 24 staff hold the National Vocational Qualification in care at level 2, with 5 enrolled, which will eventually achieve the 50 standard. Other training is of a high standard; the training matrix shows that mandatory training is up to date including, fire safety, moving and handling, first aid, Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 21 infection control and safeguarding. Other training provided includes food hygiene, accredited medication administration and dementia care. New staff receive a Skills for Care standard induction programme. A sample of four staff files were inspected including the most recent appointments and these were found to be satisfactory. Each file included evidence of a Criminal Records Bureau, (CRB) including POVA check, completed application forms, references, interview records and copies of qualification certificates. This gives the people using the service confidence that they are supported by the right staff. Staff receive a statement of terms and conditions and a copy of the GSCC code of conduct. Wetley Manor Residential Care Home Limited DS0000005033.V372168.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 - 33, 35 - 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management systems in the home are open, positive and protect the people using the service. EVIDENCE: The home is well managed by a competent and experienced manager, supported by the proprietor who takes an active role in the running of the home. While holding a good qualification the manager should demonstrate Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 23 recent management update training by undertaking the NVQ 4 in management and care or equivalent. The ethos of the home is open and transparent and promotes the involvement of people who use the service and staff in its day-to-day running. A quality assurance programme has been developed by the home and has been part implemented with a survey of views of the people using the service. As yet it has not been extended to include the views of families and other stakeholders. The process includes self-monitoring with monthly care plan reviews. The findings of the overall quality assurance process should be published for stakeholders to read and action plans derived, which can be used to inform improvement planning. The people using the service or their families take responsibility for the control of their money. The home provides support and assistance where required to secure personal allowances and written records are maintained of all transactions and receipts kept. Secure facilities are available for the safekeeping of money. Staff supervision is well established at the home and is relevant in content and well received by staff. A large sample of a variety of records were inspected across the day and without exception found to be thoroughly completed and up to date. There are good practices established to keep records secure and a number of people said they were aware that they could see records and information about them. A full range of policies and procedures are available in accordance with our guidance. Health and Safety is given appropriate priority with a broad range of monitoring and maintenance in place with all staff receiving health and safety training at induction and on annual mandatory up dates. During the tour of the building it was observed that all corridors were clear of obstructions and the premises are kept in a safe condition. Appropriate arrangements are in place for the monitoring, recording and reporting of accidents. An inspection of the service and inspection certificates identified these to be up to date. Documentation also show that staff working at the home hold up to date certificates in first aid, manual handling, food hygiene and fire safety. Wetley Manor Residential Care Home Limited DS0000005033.V372168.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 2 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 4 3 4 Wetley Manor Residential Care Home Limited DS0000005033.V372168.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. 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. Refer to Standard OP1 Good Practice Recommendations The Service User Guide should be revised to include details of fees payable and arrangements for the provision of supper and a copy available to each person using the service. This will ensure that people are able to make informed choices. The lunchtime menus should be amended to include details of alternative choices. The availability of a supper meal should be on the menu and people aware of the time of service. The provision of NVQ training should be provided to sufficient care staff to ensure the 50 standard can be maintained consistently and update training provided as appropriate. This will give people using the service confidence that they are supported at all times by appropriately trained personnel. The process of using surveys to inform the quality assurance system should be extended to include families and other stakeholders. This will provide the home with a DS0000005033.V372168.R01.S.doc Version 5.2 Page 26 2. OP15 3. OP28 4. OP33 Wetley Manor Residential Care Home Limited more comprehensive view of their service and aid improvement. Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wetley Manor Residential Care Home Limited DS0000005033.V372168.R01.S.doc Version 5.2 Page 28 - 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. 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