Care Home: Wren House

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What the care home does well People benefit from good assessments before they move in. The home makes sure it can meet people`s care and support needs. People have very detailed immediate care plans which are regularly updated. People`s nutritional needs are regularly monitored. Food and fluid charts are in place if anyone is assessed as being at risk if they do not eat or drink enough. People are offered high calorie drinks and foods if they are deemed at risk of malnutrition. Members of staff make sure that people have their call bells and fresh drinks near them if they are spending time in their bedrooms. People have good access to healthcare professionals. Any concerns about people`s health are promptly referred to the relevant professional. People can administer their own medicine following a risk assessment. Members of staff are trained to give medicines and their ongoing competency is regularly assessed. Daily reports show good evidence of the care and support given to people who use the service. Recording is factual, with good information about people making decisions in conversations with staff members. People prefer to follow their own interests and choose Wren House because organised group activities are not provided. People are asked about their social history when they move in. This means that staff members can engage with people in discussions about their life experience. Much effort is made in consulting people about the meals provided. Meals are considered a social event, with people having a drink in the sitting room together before meals. People write comments on the menus that are delivered to them each day with breakfast. Although there is a set menu, we saw that people could have virtually anything they wanted. Wiltshire Council awarded the home`s kitchen five stars. People know that they can complain to management and are confident that their issues will be addressed. People benefit from a warm, very comfortable and well maintained environment which suits their needs. Staffing levels mean that people have staff available to them when they need them. Staff have good access to training, with nearly half having an NVQ in care. A robust recruitment process means that people are protected from anyone who is unsuitable to work with them. Staff uphold people`s right to dignity and respect and good relationships are established. Mrs Twinn has over thirty years experience in providing care and support to older people. She is supported by a deputy manager who has qualifications in care management. Members of staff are well supported and supervised. People`s health and safety are regularly assessed. What has improved since the last inspection? A new care planning format has been purchased so that people`s care and support needs and any risks to their safety can be captured more fully. A complete record of all medicine received into the home is being kept. Risk assessments are in place for when people administer their own medicine, including when they prefer to take it a little later than it is given to them, for example, sleeping tablets. People who self medicate now ensure their medicine is locked in the safe storage provided. The providers` application to vary the number of places has been approved. The providers` application to register as a domiciliary care agency, in order to provide care at any time to people who live in the unregistered accommodation on site, is with our registration department. What the care home could do better: Care staff should have access to the long term care plans, as well as the immediate care and support needs sheet. This is so they have a better understanding of people`s care and support needs. When risks are assessed care plans must be reviewed and revised, with details of how assessed risks are to be minimised and monitored. Risk assessments for smoking and bathing alone must be more detailed. When people are assessed as at risk of developing pressure sores, their care plan must evidence how those risks are managed, including details of any pressure relieving equipment that is in place. The home must keep its own records of any nursing treatments and not rely on records kept by the district nurse. If the district nurse gives advice on relieving pressure, for example, that a person should be supported to stand for periods of time during the day, records must show that this is achieved. Unclear statements such as `with two carers`, `attention to diet` and `no problems` should be expanded upon. Information about special prescribing instruction should be recorded in the care plan, for example, medicine to be taken only once a week, or details of what symptoms prompt the giving of different pain relieving tablets. People`s GPs should be consulted about the use of homely remedies, to see if they can be taken with prescribed medicines. The home must continue to give life saving treatment unless they have received a legal agreement, often referred to as an `advanced statement`. Following consultation with people about the quality of the service, a report must be produced showing details of the measures the home intends to take to improve the quality and delivery of the services provided. This is in order to show how the home is improving the service and listening to what people say. Key inspection report Care homes for older people Name: Address: Wren House 32 Vicarage Street Warminster Wiltshire BA12 8JF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sally Walker     Date: 3 0 1 1 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 34 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. 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 Care Homes for Older People Page 3 of 34 Information about the care home Name of care home: Address: Wren House 32 Vicarage Street Warminster Wiltshire BA12 8JF 01985212578 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Wren House Ltd care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users that can be accommodated is 14. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Older People, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Wren House is a private residential home offering accommodation and personal care to a total of 14 older people. Respite care can also be offered. There are two sheltered flats in an adjacent building with a further eight appartments on the same site. These premises are not registered, but the people living there may have the opportunity to move into the care home at a later date, should their needs change. The home is situated close to the centre of Warminster, which offers a full range of amenities. Wren House Limited is the registered provider and Mrs Twinn is the registered manager. Mr Twinn deals with the financial and safety side of the business. Care Homes for Older People Page 4 of 34 Over 65 14 0 Brief description of the care home People are provided with their own bedrooms, twelve of which have en-suite facilities, providing either a bath or a shower. The remaining bedroom has a private bathroom directly adjacent to it. One of the bedrooms could be used as a double bedroom for couples or people who choose to share. Peoples bedrooms are located on the ground and first floor levels and stair lifts have been installed on two flights of stairs, which enable easier access to the first floor. A call bell system with an added speech facility is installed in each room. Care staffing levels are a minimum of four during the day, inlcuding a supervisor. At night there is one waking night staff and a member of staff sleeping on the premises. Information about current fee levels can be obtained directly from the home and from their website: www.wrenhousewarminster.co.uk. Care Homes for Older People Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place on 26th November 2009 between 9.00am and 4.35pm. We returned on 30th November 2009 to complete the inspection; between 9.00am and 2.00pm. Mrs Anne Twinn, registered manager, and the deputy manager were present during the inspection. We spoke with four people who use the service and one person who lived in a flat on the site and had come for lunch. We spoke with two staff members. We looked at care planning, risk assessments, medicines, menus, staffing recruitment records, staff training records and pre-admission assessments. We asked the home to complete an Annual Quality Assurance Assessment (known as the AQAA). This was their own assessment of how they were performing. It gave us some information about what has happened during the last year and about their plans for the future. Care Homes for Older People Page 6 of 34 As part of the inspection process we sent survey forms to the home for people who use the service, members of staff and healthcare professionals to tell us about the service. Comments are found in the relevant part of this report. The last Key inspection was on 4th January 2007. The last annual service review was on 25th June 2008. We made a Random inspection on 13th February 2008 because we had been told that the home had admitted a 14th person when they were only registered for 13 people. Our registration inspector made a visit to the home on 11th April 2008 to discuss the providers application to increase the number of beds; the arrangements for the Coach House; two, one bedroom flats in an adjacent building and The Orchard; 8 retirement apartments, also on the site. The providers application to vary their registration to increase the numbers to 14 was approved on 18th April 2008. The providers application to register a domiciliary care agency is with our registration department. Our pharmacist inspector made a Random inspection on 19th March 2008 as we had seen some medicine that was not locked away during our visit and the home requested advice on the arrangements for medicines. The current fee levels were between 802.00 and 879.00 pounds a week depending on need. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Care Homes for Older People Page 7 of 34 What the care home does well: People benefit from good assessments before they move in. The home makes sure it can meet peoples care and support needs. People have very detailed immediate care plans which are regularly updated. Peoples nutritional needs are regularly monitored. Food and fluid charts are in place if anyone is assessed as being at risk if they do not eat or drink enough. People are offered high calorie drinks and foods if they are deemed at risk of malnutrition. Members of staff make sure that people have their call bells and fresh drinks near them if they are spending time in their bedrooms. People have good access to healthcare professionals. Any concerns about peoples health are promptly referred to the relevant professional. People can administer their own medicine following a risk assessment. Members of staff are trained to give medicines and their ongoing competency is regularly assessed. Daily reports show good evidence of the care and support given to people who use the service. Recording is factual, with good information about people making decisions in conversations with staff members. People prefer to follow their own interests and choose Wren House because organised group activities are not provided. People are asked about their social history when they move in. This means that staff members can engage with people in discussions about their life experience. Much effort is made in consulting people about the meals provided. Meals are considered a social event, with people having a drink in the sitting room together before meals. People write comments on the menus that are delivered to them each day with breakfast. Although there is a set menu, we saw that people could have virtually anything they wanted. Wiltshire Council awarded the homes kitchen five stars. People know that they can complain to management and are confident that their issues will be addressed. People benefit from a warm, very comfortable and well maintained environment which suits their needs. Staffing levels mean that people have staff available to them when they need them. Staff have good access to training, with nearly half having an NVQ in care. A robust recruitment process means that people are protected from anyone who is unsuitable to work with them. Staff uphold peoples right to dignity and respect and good relationships are established. Mrs Twinn has over thirty years experience in providing care and support to older people. She is supported by a deputy manager who has qualifications in care management. Members of staff are well supported and supervised. Peoples health and safety are regularly assessed. Care Homes for Older People Page 8 of 34 What has improved since the last inspection? What they could do better: Care staff should have access to the long term care plans, as well as the immediate care and support needs sheet. This is so they have a better understanding of peoples care and support needs. When risks are assessed care plans must be reviewed and revised, with details of how assessed risks are to be minimised and monitored. Risk assessments for smoking and bathing alone must be more detailed. When people are assessed as at risk of developing pressure sores, their care plan must evidence how those risks are managed, including details of any pressure relieving equipment that is in place. The home must keep its own records of any nursing treatments and not rely on records kept by the district nurse. If the district nurse gives advice on relieving pressure, for example, that a person should be supported to stand for periods of time during the day, records must show that this is achieved. Unclear statements such as with two carers, attention to diet and no problems should be expanded upon. Information about special prescribing instruction should be recorded in the care plan, for example, medicine to be taken only once a week, or details of what symptoms prompt the giving of different pain relieving tablets. Peoples GPs should be consulted about the use of homely remedies, to see if they can be taken with prescribed medicines. The home must continue to give life saving treatment unless they have received a legal agreement, often referred to as an advanced statement. Following consultation with people about the quality of the service, a report must be produced showing details of the measures the home intends to take to improve the Care Homes for Older People Page 9 of 34 quality and delivery of the services provided. This is in order to show how the home is improving the service and listening to what people say. 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. Care Homes for Older People Page 10 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from good assessment of their care and support needs before they move in. This means that they can know whether the home is suitable for them. Evidence: Mrs Twinn or the deputy manager carried out the pre-admission assessments with people who were considering moving in. Information was gained from the person and those involved in their care. Any specialist equipment or services were set up before the person moved in, so that continuity of care was achieved. People and their families were encouraged to look round and talk about the home to make sure that it was suitable for them. Care planning information was available on the day that people moved in. An up to date statement of purpose was made available to people who were considering moving in. People were provided with a contract giving more information about the facilities and services included in the fees. Information about the service is Care Homes for Older People Page 12 of 34 Evidence: also on the homes website www.wrenhousewarminster.co.uk One of the people we spoke with told us that they had always known about the home, so they knew what to expect when they moved in. Another person told us that they had moved in from The Orchards, a separate apartment block on the site, and had known what to expect from the home. A further person told us they had made a visit to the home to view the accommodation and meet staff members before they moved in. Another person told us we went to four or five different homes before we decided on this one. Care Homes for Older People Page 13 of 34 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is good information about how peoples care and support needs are met and monitored, but this is not always brought together in a care plan. Very detailed immediate care plans show the amount of effort put into meeting peoples daily short term needs. Daily reports show good evidence that people are making their own decisions, although some unclear statements should be avoided. Evidence: We looked at peoples care plans. At the last inspection of 4th January 2007 we advised that the care plans needed more information about peoples needs and how they were to be met. The home had purchased a format so that they could record peoples care needs, risk assessments, medical interventions and changes of medicine and review them more easily. Mrs Twinn told us that the care plan folders were only available to herself and the deputy manager. We thought that staff should have better access to the whole care plans. Care staff worked to a detailed immediate care plan for individual people. We said that this was very good evidence of the amount of effort the home made to meet individual needs. We thought that the home could easily devise a format which would capture all of the information held in different places. Care Homes for Older People Page 14 of 34 Evidence: This would show how peoples care and support needs were to be met and monitored and reduce duplication of information. At the last inspection we made a requirement that peoples risk assessments were more comprehensively completed. The new care planning format provided for assessment of risk in a number score to show level of risk. At this inspection we acknowledged the effort made to address the requirement we had made about more detailed care planning. We discussed the issues in having a number outcome for risk assessments, which did not necessarily show how risks were to be minimised or monitored. We thought that the home could easily devise a format which was more accessible to staff and showed clearly the individual management of risks. We advised that risk assessments about smoking should be more detailed. Mrs Twinn told us that people could have a bath every day if they wanted but most people chose to have one once or twice a week. The deputy manger told us that baths tended not to be given at weekends due to reduced staffing levels, but should a resident request a bath on any day of the week, it would be given. She also told us that some people preferred to bath on their own. We said that individual risk assessment must be carried to ensure peoples safety when bathing alone. The home did not have a hoist. The deputy manager said that currently no one needed lifting with a hoist and that in the past a hoist had been rented when needed. She went on to say that slide sheets were available. Some peoples ensuite baths had hoists so they could be supported in and out of the bath. The home was using parts of the Malnutrition Universal Screening Tool to assess peoples nutritional needs. The deputy manager told us that food and fluid charts would be put in place if anyone was at risk. These charts were kept in individuals bedrooms. We saw people being encouraged to have different things when they refused to have the meal or said they were not hungry. Mrs Twinn told us that fortifying drinks, cream, milk puddings and ice cream were available to increase peoples calorie intake. Peoples risk of developing pressure damage was being assessed using the new recording format. We said that where risks were identified, the care plan must show how those risks were to be minimised and what pressure relieving equipment was in place. Staff members had recently been trained in prevention of pressure sores. Mrs Twinn told us that the district nurse would be involved if risks were identified and showed us the nursing notes. She also told us about low air loss mattresses which had been provided for people who were at risk. We said that the care plans must show this Care Homes for Older People Page 15 of 34 Evidence: detail and the home should write their own records, rather than relying on those of the district nurse. One example was where the district nurse had advised that one person should be supported to stand for a time to relieve the pressure of sitting for periods of time. We could not establish from the records whether this was being carried out on a regular basis, as there were only two entries for September 2009 to show that it had been achieved. We saw very good evidence in the daily reports of how the care was provided. There was very good evidence of peoples decision making and choice. Staff recorded conversations and interventions, nutritional monitoring, medical interventions and changes and how people were feeling. We saw that much of the information about people was in the daily report and other documents and letters, rather than being brought together into a plan of care that could be reviewed. We also advised that unclear statements such as with two carers, attention to diet, normal diet and no problems should be expanded upon. Some people had refused to have their photograph taken for the homes records. They had signed a statement to reflect this. Most people had also signed their care plans. Some people had chosen not to be checked during the night for different reasons. We saw that all of the people we spoke with in their bedrooms had their call bells within easy reach. They also had fresh jugs of water or juice within easy reach. People told us that Mrs Twinn would organise visits from their GP if needed. We saw that people had good access to healthcare professionals or specialists. The records of peoples medical history and results of GP visits were very detailed. At the Random inspection of 13th February 2008 we saw that one person who was administering their own medicine was keeping it on their dining table. We made a requirement that people who were self medicating must have a lockable facility for storage of their medicine so that it was not accessible to anyone else. As a result of discussions about medicine at the Random inspection, we asked our pharmacist inspector to make a visit to the home to give advice and ensure the safe management of medicine. Our pharmacist advised that all medicine received into the home must be recorded and we found that this was being done. Our pharmacist said that a new sheet that the home had devised for recording medicine to be taken only when needed, would give a more accurate picture of what medicines had been taken and for what reason. We advised that further detail should be included to show what symptoms prompted this medicine to be given, for example, different pain relief. Information about special prescribing instruction should also be recorded in the care Care Homes for Older People Page 16 of 34 Evidence: plan, for example, medicine to be taken only once a week. Our pharmacist inspector saw that some people preferred to take their medicine later than it was given to them, for example, sleeping tablets. In order to continue to allow people choice and independence in managing this medicine, our pharmacist said that individual risk assessments and care plans must be done with a code to indicate that staff had not seen the medicine taken. This was now being done. People could administer their own medicine following a risk assessment. Staff members ordered their medicine and checked it when it arrived; the person then signed the record to say that they have been given their medicine. All but one of the people we spoke with told us that staff members administered their medicine. One person who administered some of their own medicine told us that they kept it locked in their bedside cabinet. Medicine was kept in a lockable cabinet with any controlled medicine kept in a small safe with a double lock. There was a list of staff members who had been assessed as competent to administer medicine. Ongoing competency was regularly assessed and recorded. The homes medicine policy was kept at the front of the medicine administration record for easy access. Staff members had undertaken medicine training in April and May 2009. We said that body maps may help with identifying where on the body different topical creams or medicine patches should be applied. A fridge was available for storage of some preparations. We said that a list of the homely remedies available should be sent to each persons GP for them to confirm that they could take it with their current medicine. We also said information about any risks of taking homely remedies or other proprietary medicines with prescribed medicine could be included in the statement of purpose or service users guide, so that people or their families knew the risks involved. We saw that some care plans had statements about peoples preference in not being resuscitated. We said that the home should not make any decisions about resuscitation and continue to save life, unless anyone had an advanced statement, often referred to as a living will. Any legal agreement about advanced statements was between the person and their GP. In a survey one of the healthcare professionals told us Provides high individual care. Wren House always has a very high standard of hygiene and asks advice about any Care Homes for Older People Page 17 of 34 Evidence: problems they have with residents that as a neighbourhood team we provide. Residents are usually very happy. Another healthcare professional told us The service user has choice on all aspects of their daily lives, meals, get up/bed times, personal dignity is at a very high standard, food choice is exceptional, cleanliness is very high and rooms are decorated and maintained to a very high standard. This residence is run and maintained like a 5 star hotel and not an old peoples residential home. The service provided leaves very little for improvement for the users. An exceptional residential home. In a survey one of the GPs told us Cares for people with full attention to their needs medical, social spiritual. It is a 1st class establishment well run and all the GPs at this practice would be happy to go there if they needed care in the future. Care Homes for Older People Page 18 of 34 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People know that the home does not prove an activity programme before they move in; this is often why they choose Wren House, as they prefer their own interests. The home makes a lot of effort to make sure that people enjoy the meals. There is a set menu but people tell the cook what alternatives they would like. Evidence: We asked people about their daily routines. One person told us that the home did not appear to have any routines. They said I do what I like. I go to the dining room for lunch. They told us they played cards, watched television and read the paper. They said I couldnt be looked after much better. Another person told us I dont do anything, Ive got my books. There is a lady who gets books for us. Mrs Twinn told us that people are made aware that the home does not provide activities at the first point of contact. She went on to say that most people said that they chose Wren House precisely because organised activities were not provided. We saw that the service users guide stated that a programme of activities was not available. The home had started to include peoples life history as well as their medical histories Care Homes for Older People Page 19 of 34 Evidence: in peoples care assessments. Mrs Twinn told us how it enhanced understanding of peoples needs. She gave an example of how staff members had a better understanding of the army or naval services. One person enjoyed talking about their services career and showing staff members their photographs. One of the people we spoke with told us about their interests and how they spent their day. They told us they rarely left their room and had all their meals in their bedroom. They told us the food is really quite good; too much, Ive got fat. Some people told us about the local church providing Holy Communion once a month in the sitting room. Most of the people we spoke with did not know what they were having for lunch when we asked them. One person told us I dont know until I get down there. The foods pretty good. We saw that the lunch menus were delivered to people with their breakfast trays. People wrote on the menus to tell members of staff if they preferred something different to the published menu. There was a set menu for lunch and supper with an omelette with different fillings, salads, sandwiches with different filling, scrambled egg and banana as alternatives. The supper menu had three courses. There were records of other things that people had been given as alternatives to the menu. Most people meet in the drawing room to have a drink before lunch. Mrs Twinn told us that people had different drinks including sherry, wine or spirits. Two people who lived in the Coach House came to have their lunch which was included in their fees. We saw that one person who was having their meal in their bedroom was taken two choices of pudding so they could see which one to choose. In a survey one of the people who use the service told us They do all that is necessary and more besides. Another person told us This is easily the best care home for miles around to suit my requirements. The food is not always suitable for my diet and the meat could be more tender. One of the people we spoke with told us the food is very good, well presented with lots of vegetables. Another person told us Im not keen on stews. I like egg and bacon. Care Homes for Older People Page 20 of 34 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is making sure that people know how to make a complaint. People are confident that their complaints will be listened to and addressed. Members of staff are confident in reporting any allegations or observations of abuse to management. Staff were trained in recognising all forms of abuse. Evidence: We asked people about what they would do if there was anything they were not happy with or they wanted to make a formal complaint. Most people said they would talk to members of staff or Mrs Twinn. One person told us that in the past an item of clothing had been replaced due to problems with the laundry. Another person told us I would just phone up and tell them. Everyone said they had nothing to complain about. Mrs Twinn told us that she had identified in the quality audit that people did not know how to make a complaint. She told us that she was writing to people and their representatives to let them know about the homes complaints procedure. The home had a complaints log which showed evidence of investigations, outcomes, apologies if complaints were upheld and response to complainants. The home also kept a record of positive feedback from people who use the service and their families. Mrs Twinn gave us examples of how she had challenged discrimination and attitudes in consideration of the diversity and equality of people who use the service and staff members. Care Homes for Older People Page 21 of 34 Evidence: We asked members of staff about the local safeguarding procedure. They told us that they would report any allegations or observations of abuse to senior management. They also told us about the local booklet entitled No Secrets in Swindon and Wiltshire where they would find contact numbers for the local safeguarding adults unit. We saw that members of staff had undertaken training in safeguarding people from abuse. This took the form of a DVD and questionnaire. We advised that training should also be sought in the local safeguarding procedure. Care Homes for Older People Page 22 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a warm, very comfortable and well maintained environment that suits their needs. Evidence: Twelve of the thirteen bedrooms have ensuite facilities with either a bath or shower and toilet. The other bedroom has its own private bathroom next to the bedroom. There are two stair lifts to access the first floor in the older part of the home and the upstairs in the newer part. People had brought items of furniture and pictures to personalise their bedrooms. The majority of the bedrooms were spacious and had views of the grounds. Some bedrooms opened onto patio areas and people told us they sat outside in the summer. There were different seating areas along the corridors. All of the radiators in the bedrooms and communal areas were guarded to reduce peoples risk of scalding should they have prolonged contact with them. All of the hot water outlets had been fitted with thermostatic controls to reduce the risk of scaling. The controls were regularly checked and there was an accompanying risk assessment. There were free standing radiators for use should the central heating system fail. There was a risk assessment for their use and guidance about making sure the cables were not a trip hazard. The home was very well decorated and furnished in keeping with the age of the building. The home was very well maintained. Care Homes for Older People Page 23 of 34 Evidence: The homes call alarm system was linked to an intercom in the kitchen which members of staff answered when people called. We saw that members staff also used the intercom to ask people what they wanted for their mid morning hot drink. There were listening devices in the kitchen. Mrs Twinn told us that they had been used in the past so that night staff could hear the alarm system at different ends of the building. Mrs Twinn confirmed that they were never used to monitor people who use the service. She confirmed that they would be taken away as the call alarm system was now audible all over the building. In a survey one person told us Keeps it fresh and clean. One of the people we spoke with told us the cleaning staff are quite delightful. Another person described the laundry service as excellent. Wiltshire Council Environmental Health Department had awarded the homes kitchen five stars in January 2008. Care Homes for Older People Page 24 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from having staff members available when needed. Staff are trained and have experience of providing care. A robust recruitment process is in place. People are protected from anyone who is unsuitable to work with people who may be vulnerable. Members of staff uphold peoples right to dignity and respect and good relationships are established. Evidence: The staffing rota showed that there was a minimum of four care staff members, including a supervisor, two housekeepers, the cook and handyman on duty during the mornings, throughout the week. During the afternoons and evenings there were three care staff and a supervisor. At night there was one waking night staff and a member of staff sleeping on the premises. Mrs Twinn and the deputy manager were on duty or on call throughout the week. A diary was available for staffs care and work routine to be planned for each day. Mrs Twinn told us that she had advertised for bank staff. Staff recruitment files contained all the information and documents required by regulation. No one started working at Wren House until checks on their suitability to work with vulnerable people had been established. Care Homes for Older People Page 25 of 34 Evidence: Mrs Twinn told us that members of staff are expected to address people by their title and only to refer to people by their first name if they have asked them to. We saw that staff had built up good relationships with people and were engaging in a respectful and friendly manner. Planned training was shown on the daily planning file. In addition there was a training matrix showing essential training to be undertaken. This included: infection control, abuse, food hygiene, moving and handling, dementia care, death and bereavement, pressure sore prevention, first aid, person centred care and communication. The deputy manager told us that moving and handling training consisted of a DVD, questionnaire and practical demonstration. She said that she held a qualification so that she could provide moving and handling training. Ten staff members held NVQ Level 2 in care; one was undertaking NVQ Level 3 and the deputy manager held NVQ Level 4. In a survey one person told us Most of the staff are wonderful and very caring. Another person told us Carers are excellent. A further person told us marvellous staff. They are all very nice, fantastic. They come almost immediately if I call. Someone else told us they are lovely people I get on very well with them. One person described the staff as very polite. Another person told us I am exceptionally well looked after. The staff are good fun. Care Homes for Older People Page 26 of 34 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Mrs Twinn is very experienced in providing care and support to older people. She is supported by a deputy manager who has qualifications in care management. The home is run in peoples best interests. Peoples health and safety are well managed. Members of staff are well supported and supervised. Evidence: Mrs Twinn has managed the home for nearly thirty years. She told us about her experience of providing care in nursing homes and hospital, prior to setting up Wren House. Mrs Twinn did not have the Registered Managers Award or NVQ Level 4 in management and care. However the deputy manger had gained the Registered Managers Award and NVQ Level 4. Mrs Twinn told us she would review the current management arrangements once the Health and Social Care Act 2008 (Registration Requirements) Regulations 2009 came into force. Mrs Twinn and the deputy manager had recently attended the deprivation of liberty safeguards code of practice and personalisation training. The deputy manager told us Care Homes for Older People Page 27 of 34 Evidence: that the home was registered with Skills for Care and regularly attended their training programme. We made Random inspections on 13th February 2008 because we had been told that the home had admitted a 14th person when they were only registered for 13 people. Our registration inspector made a visit to the home on 11th April 2008 to discuss this application and the arrangements for the Coach House, two, one bedroom flats in an adjacent building and The Orchard, 8 retirement apartments, also on the site. Mrs Twinn said that personal care would be provided in an emergency and contact made with next of kin or emergency medical services. Mrs Twinn described a period of 6 months where personal care was provided until a vacancy became available at Wren House. Mrs Twinn was served with a notice informing her of a breach of regulation with regard to carrying on an unregistered domiciliary care agency. The providers application to register as a Domiciliary Care Agency was with our registration department. This was to ensure that if in future people who lived in the Coach House and needed any personal care, it could be provided by the home. The providers application to vary their registration to increase the numbers to 14 was approved on 18th April 2008. Mrs Twinn told us that Mr Twinn manages the business and financial elements of the company. We saw that he had also carried out the annual environmental risk assessments to the building and grounds, use of equipment and tasks that staff members may be involved with. Staff members had received training in fire safety, infection control, moving and handling, food hygiene and first aid. Staff files showed evidence that they were receiving regular supervision. There was a supervision plan for the year. The home does not hold any money on peoples behalf. People manage their own finances or this is done by their family or solicitor. The home sent out yearly questionnaires to people and others to seek their views on the service. It was clear from talking with Mrs Twinn that action had been taken to address any comments received. We said that in order to fully meet the regulation about quality of care, the home must produce a report showing details of the necessary measures the home intends to take to improve the quality and delivery of the services provided. One of the people we spoke with told us that Mrs Twinn comes periodically to ask me Care Homes for Older People Page 28 of 34 Evidence: if there is anything I want. She is always calling to see if Im all right. In a survey one of the staff told us can always rely on our manager for advice. Care Homes for Older People Page 29 of 34 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 30 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 When people are assessed as at risk of developing pressure sores, their care plan must evidence how those risks are managed, including details of any pressure relieving equipment that is in place. As eveidnce of good care planning 01/03/2010 2 7 13 When risks are assessed 01/03/2010 care plans must be reviewed and revised with details of how assessed risks are to be minimised and monitored. Risk assessments for smoking and bathing alone must be more detailed. As evidence of good care management 3 8 13 The home must continue to give life saving treatment to people unless they have received a legal agreement, 01/03/2010 Care Homes for Older People Page 31 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action often referred to as an advanced statement. The home has a duty of care to save a life. 4 8 15 The home must keep its own 01/03/2010 notes on any treatments or wounds and not rely on district nursing notes. The size, colour and depth of wounds should be recorded together with a record of whether the skin is broken. As evidence of good care planning 5 33 24 Following consultation with people about the quality of the service, a report must be produced showing details of the necessary measures the home intends to take to improve the quality and delivery of the services provided. To show how the home is improving the service and listening to what people say. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 01/03/2010 1 7 Unclear statements should be avoided in records. Care Homes for Older People Page 32 of 34 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 2 3 4 7 8 9 Information about peoples care and support needs should be rationalised and brought together into the care plan. The home should review whether a hoist should be available if anyone sustained a fall. Information about special prescribing instruction should be recorded in the care plan, for example, medicine to be taken only once a week or details of what symptoms prompt giving of different pain relief. Peoples GPs should be consulted about the use of homely remedies, to see if they can be taken with prescribed medicines. Body maps may help with identifying where on the body different creams or medicine patches should be applied. Staff members should be offered external training in the local safeguarding procedure. 5 9 6 7 9 18 Care Homes for Older People Page 33 of 34 Helpline: 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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