Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
Wynne Crest
23/25 Cadwgan Road
Old Colwyn
LL29 9RE
Type of Inspection – Baseline
Date(s) of inspection – Friday, 10 April 2015
Date of publication – 13 May 2015
Welsh Government © Crown copyright 2015.
You may use and re-use the information featured in this publication (not including logos) free of charge in any
format or medium, under the terms of the Open Government License. You can view the Open Government
License, on the National Archives website or you can write to the Information Policy Team, The National
Archives, Kew, London TW9 4DU, or email: [email protected]
You must reproduce our material accurately and not use it in a misleading context.
Page 1
Page 2
Summary
About the service
Wynne Crest is a care home providing personal care for up to 21 people over the age of
60. The conditions of registration allow for one named person with dementia to be
accommodated. The company Wynne Crest Ltd is registered as provider and Christina
Markham is the responsible individual for the organisation. The registered manager is
Malcolm Delamare.
The home is situated in a residential area close to local facilities and the sea front.
What type of inspection was carried out?
We, Care and Social Services Inspectorate Wales (CSSIW) visited the home on 10/04/15
between the hours of 9 am and 4:45 pm. This was an unannounced baseline inspection.
Information for this report was gathered from the following sources:
Discussions with people using the service, the registered manager and staff on
duty.
A sample of records in relation to people using the service, staff and operation of
the home.
Our observations during the inspection visit. This included observation using the
Short Observational Framework for Inspection (SOFI) tool. The SOFI tool enables
inspectors to observe and record life from a service user’s perspective; how they
spend their time, activities, interactions with others and the type of support
received.
What does the service do well?
We did not observe any areas of significant good practice that went beyond expected
standards during our visit.
What has improved since the last inspection?
At the last inspection, the service was not compliant with regulations due to there being no
registered manager in post. This has now been addressed and the person appointed to
manage the home is now registered to do so.
What needs to be done to improve the service?
The service is not compliant with regulation 19(2) (d) of the Care Homes (Wales)
Regulations 2002. This is because the registered person has not demonstrated that
service users are safeguarded through robust recruitment and vetting practice. This is a
serious matter and we have issued a non compliance notice to the registered person.
The service was not compliant with Regulations 25 (3) of the Care Homes (Wales)
Regulations 2002. This is because the service had not produced an annual quality of care
review report demonstrating the systems in place for monitoring, reviewing and improving
the quality of care provided. The views of people using the service, their representatives,
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staff and commissioners had not been represented in a report. We have not issued a non
compliance notice because there was no immediate impact on people using the service
and the next annual review was due. The registered person is reminded that a report must
be produced following this review. This area of non compliance will be reviewed at the
next inspection.
To ensure people receive consistent and appropriate care, service user plans should set
out in greater detail how each person’s care needs are to be met and reflect the person’s
personal choices, what they can do for themselves and, if support is needed, the level of
assistance required. Where a Deprivation of Liberty Safeguards (DoLS) authorisation is in
place (or requested), it needs to be clear in the service user plan what action is being
taken to achieve positive outcomes for the person concerned.
The registered person should consider introducing a supportive tool such as The North
Wales Falls Multifactorial Risk Assessment (MRA) and care plan, or similar research
based document. This will benefit people using the service as it is designed to identify a
person at risk of falling and prevent further falls.
To preserve people’s dignity and right to privacy the registered person must ensure that
communal bathrooms and toilets are lockable. Locks should be suited to service users’
capabilities and accessible to staff in emergencies.
There should be a structured system in place to give an up to date account of what staff
training has been delivered and when refresher training is needed. The benefit of this for
people using the service is that they can be confident that they will be cared for by a staff
team that can demonstrate that their training is continuously updated.
To monitor performance, provide support and professional guidance and identify training
and development needs, one to one supervisions with care staff should consistently be
undertaken at least once every two months.
The registered person should review the statement of purpose and operational policies
and procedures as part of the home’s quality assurance process to ensure they are up to
date and meet current good practice guidance. The benefit of this for people using the
service is that their rights, health and best interests will be safeguarded by robust policies
and procedures which are consistently implemented and constantly monitored by the
management.
To strengthen the systems in place in regard to moneys managed on behalf of people
using the service, signatures of all transactions made should be countersigned with
balances checked regularly.
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Quality Of Life
Overall, we found there was a relaxed and friendly atmosphere within the home and
observed people being treated respectfully. There was, however, room for improvement
in documenting how people’s care is to be provided.
We found that people are treated with dignity and respect. People told us that they got on
well with the staff and that they were very caring. During our visit we saw people being
approached in a polite and friendly manner. We saw staff being alert as to when people
needed support with personal care, giving discreet assistance. We heard staff using
respectful language when talking with people and when discussing their care needs. We
saw that people were dressed in freshly laundered clothes with attention paid to personal
appearance. We observed staff knocking on people’s doors and waiting for a reply before
entering. We did, however, notice that people’s dignity and right to privacy was
compromised somewhat by a communal bathroom with a toilet that could not be locked.
We raised this issue with the registered manager at the time for corrective action.
There are some opportunities for people to be occupied. This is because the staff
organise activities for people to take part in if they choose. We were told that the home
did not have a planned daily activities programme, rather that activities were arranged
depending on what people wanted to do each day. When we spoke with people they said
there was enough to occupy their time and that staff organised activities. During our visit
we observed people spending time in the communal areas chatting with staff or listening
to music. We observed people discussing with staff what they would like to do and saw
that some chose to have manicures. We were also told of visits by external entertainers.
We spoke with people who chose to spend their time privately in their rooms and
observed people entertaining visitors. We were told that visitors could call at any time
and are always made welcome, which we observed during our visit.
We found that people are enabled to have access to medical and specialist support.
When looking at records we saw evidence that advice, treatment and professional
assessment is sought. We saw community nurses visiting their patients at the home
during our visit and saw evidence in the records of referrals to community mental health
services.
We found that people using the service may not always experience appropriate
responsive care from staff with an up to date understanding of their individual needs and
preferences. This is because of the way the care to be provided is documented. We saw
that people had a plan of care and that these were being reviewed. We found, however,
that plans did not include detail on how all care needs were to be met. One plan showed
that a person could sometimes become distressed and agitated. This was being
monitored with support from professionals for assessment purposes but the written plan
did not give detail about known triggers that would cause the person to become
distressed, how to avoid this and strategies to be used to reduce the anxiety. However,
when speaking with the manager and staff they knew the person’s care requirements
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well. When we looked at a plan where a Deprivation of Liberty Safeguards (DoLS)
authorisation had been requested, this did not give any information on how positive
outcomes for the person concerned were to be achieved. Again, although not
documented, when we spoke with the manager and staff they knew how to support the
person. We pointed out that plans should reflect in more detail what people could do
themselves and, where they needed assistance the level of support required. We
suggested that when amendments are made to service user plans, this be done in a
clearer way as the current format is confusing. When looking at incident records we
further advised that a researched based tool designed to identify a person at risk of
falling and prevent further falls/injury be incorporated into service user plans, particularly
where falls had already occurred.
Our visit covered the lunchtime period and we found that the meal was well presented
and plentiful. We saw staff being attentive to people without being obtrusive, assisting
people to enjoy their meal in a relaxed atmosphere. We saw that drinks were provided
throughout the day.
We observed staff demonstrate care and concern for people using the service and saw
people responding positively demonstrating that people using the service experience,
warmth in their interactions with staff.
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Quality Of Staffing
In summary, we found that people receive care in a timely way from staff they are
comfortable with. We did, however, find weakness in the arrangements for supervising
staff and evidencing an ongoing staff training programme.
We found that people receive timely support and care. There were fourteen people using
the service at the time of our visit. The manager, assistant manager and five carers were
on duty. We saw this team being attentive to people and people told us that staff are
always quick to respond to requests. We saw examples of this during our visit. Staff did
not appear rushed and call bells were responded to promptly. When we spoke with
people using the service they said that this is always the case. Care records showed that
staff report on the wellbeing of each person during their shift and we observed this being
discussed by staff during a handover meeting. Duty rotas showed that staffing levels at
the time of our visit were typical and that there are two carers on duty at night (awake).
We found that care giving is relaxed and that people have time to talk to staff and feel
listened to. We saw carers being attentive to people, approaching them in a calm and
relaxed way. Staff interacted positively with people spending time chatting with them,
taking interest in what they were saying and including others in the conversation People
we spoke with commented on the friendliness of the staff. We observed humour and
good natured chatter in the interactions between the staff and people using the service.
People cannot feel completely confident that their care will be provided by competent and
confident staff. This is because there was no reliable system to evidence what training
has been delivered, the date of the training and when refresher training would be
beneficial. When we spoke with staff they told us that they were up to date with their
training, and that refresher training was ongoing. We spoke with carers who had
completed nationally recognised qualification in care at level 3 and told that they were
about to have refresher training in dementia care. However, when we asked to see a
record of the training provided this was not available. Some certificates and attendance
lists were presented but there was no structured system in place to give an up to date
account of what staff training had been delivered and when refresher training was
needed. We were told by the registered manager that he intended to put a system in
place that would easily identify the training requirements of the staff team.
Staff told us that they felt supported to do their job competently and that the staff team
shared good working relationships. The manager was described as approachable and
available to staff for support. When we looked at staff supervision records, however, we
found inconsistencies in the regularity of these meetings. Some were within the expected
time frame of 2 months while other showed November 14 as the last supervision date.
Page 7
Quality Of Leadership and Management
There has been a change in the management structure of the home since the last
inspection. A new manager has been registered and an assistant manager appointed. An
additional senior carer position has also been created. The responsible individual
continues to oversee the management of the home.
Generally, people using the service, working in the service or linked to the service are
clear about what it sets out to provide. We saw when looking at records that pre
admission assessments are carried out before offering someone a place at the home and
assessments from the commissioning authority sought. We saw that there are
operational policies and procedures in place which, until recently had not been reviewed
for some time. The newly registered manager was undertaking this task and identifying
where procedures needed updating. We advised that this be continued to ensure they
are in line with current good practice guidance.
A statement of purpose is available to interested parties. However, again this requires
updating to reflect recent changes in the service. The age of the people accommodated
and change in the management structure being examples. It is also shown that the home
has one placement for a person with memory loss. When looking at documents we saw
recordings that suggested that this number had increased and advised the registered
manager to consider whether the statement of purpose and current conditions of
registration accurately reflect the service being provided.
We saw that a questionnaire survey had been carried out to monitor the service provided
in March 2014, which demonstrates that people using the service are actively involved in
defining and measuring the quality of the service. We were not presented with evidence
to show that this information is collated to feed into a structured quality assurance
process, showing how people experience a consistent service based upon quality
improvement. The review had been carried out by the previous manager and when we
asked to see a copy of a care review report, this was not available.
We looked at the systems in place for managing medicines, handling people’s money
and recruiting staff to further test whether the service is operated with due care and
attention to minimum standards and regulations. We found medication procedures to be
satisfactory with arrangements in place for pharmacy audits to be carried out advising on
safe procedures to be followed. Records and discussions with carers demonstrated that
staff administering medication had received training.
Records are held in regard to any moneys managed on behalf of people showing what
has been received and spent with receipts obtained for any purchases. The records we
saw only had one signature against a transaction and we advised that the record should
be countersigned and that the balances be checked regularly by a senior person.
When we looked at a sample of staff recruitment records we found that these did not
demonstrate that robust procedures had been followed, which is an area of non
compliance.
Page 8
We found that people see visible accountability and know that there are people who are
over seeing the service. This is because the responsible individual visits the service
regularly. We saw this when looking at reports of visits and email correspondence.
Page 9
Quality Of The Environment
Overall we found that Wynne Crest provides a clean and comfortable environment for
people to live in.
People find the environment, fresh and clean because good standards are maintained.
All areas we saw were fresh, clean and tidy with no unpleasant odours noted. There was
evidence of a general refurbishment and improvement programme in place. Examples of
some improvements we saw included new flooring in the hallway and some of the
bedrooms and general re decoration. We were told that the next project was installation
of new stair lifts.
We found that people can feel reassured by an environment which helps to reinforce a
sense of identity. This is because people are able to arrange their rooms to their liking.
We saw that people had personalised rooms to varying degrees with their own pictures,
ornaments and memorabilia.
Visitors to the home feel welcome, comfortable and relaxed. This is because there are no
restrictions on visiting and people can entertain their guests either in one of the
communal areas or in the privacy of their own rooms. People told us that their visitors are
always made welcome. We saw that there were areas of the home that were not
accessible to service users and visitors, the rationale being that this was in the interests
of health and safety. People had unrestricted access to their accommodation and
communal areas. There was a coded lock on the entrance door, however this did not
prevent people leaving the building as the code was on display. The registered manager
was in the process of requesting DoLS authorisations for people deemed to be at risk if
going out unsupervised and who would be prevented from doing so to minimise the risk.
We found that people can be confident that the premises and equipment are safe
because servicing of appliances and equipment is kept up to date. We found evidence of
this in the sample of records we looked at. This included the home’s fire risk assessment
which had been reviewed within the last 12 months. An audit by the fire and rescue
service in October 2014 had been satisfactory. Records showed that hoists are serviced
under contract and that staff received training in manual handling and fire safety in
September 2014. We noted that the home had been awarded a score of 4 (good) for safe
food handling. We did advise the registered manager to make the storage of everyday
cleaning products more secure.
People can be reassured that they can be safe from strangers entering the premises,
that their personal belongings are secure and that personal information about them is
properly protected. We were unable to gain entry into the building without ringing the bell
which was answered by staff. We were asked for proof of identity and encouraged to sign
our name and our time of arrival and departure in the visitor’s book. We saw that
people’s personal information is kept securely.
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How we inspect and report on services
We conduct two types of inspection; baseline and focussed. Both consider the experience
of people using services.
Baseline inspections assess whether the registration of a service is justified and
whether the conditions of registration are appropriate. For most services, we carry out
these inspections every three years. Exceptions are registered child minders, out of
school care, sessional care, crèches and open access provision, which are every four
years.
At these inspections we check whether the service has a clear, effective Statement of
Purpose and whether the service delivers on the commitments set out in its Statement
of Purpose. In assessing whether registration is justified inspectors check that the
service can demonstrate a history of compliance with regulations.
Focused inspections consider the experience of people using services and we will
look at compliance with regulations when poor outcomes for people using services are
identified. We carry out these inspections in between baseline inspections. Focussed
inspections will always consider the quality of life of people using services and may look
at other areas.
Baseline and focused inspections may be scheduled or carried out in response to concerns.
Inspectors use a variety of methods to gather information during inspections. These may
include;
Talking with people who use services and their representatives
Talking to staff and the manager
Looking at documentation
Observation of staff interactions with people and of the environment
Comments made within questionnaires returned from people who use services, staff
and health and social care professionals
We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of
service are referred to within our inspection reports.
Further information about what we do can be found in our leaflet ‘Improving Care and
Social Services in Wales’. You can download this from our website, Improving Care and
Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW
regional office.
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Care and Social Services Inspectorate Wales
Care Standards Act 2000
Non Compliance Notice
Adult Care Home - Older
This notice sets out where your service is not compliant with the regulations. You, as the
registered person, are required to take action to ensure compliance is achieved in the
timescales specified.
The issuing of this notice is a serious matter. Failure to achieve compliance will
result in CSSIW taking action in line with its enforcement policy.
Further advice and information is available on CSSIW’s website
www.cssiw.org.uk
Wynne Crest
23/25 Cadwgan Road
Old Colwyn
LL29 9RE
Date of publication: 13 May 2015
Welsh Government © Crown copyright 2015.
You may use and re-use the information featured in this publication (not including logos) free of charge in any
format or medium, under the terms of the Open Government License. You can view the Open Government
License, on the National Archives website or you can write to the Information Policy Team, The National
Archives, Kew, London TW9 4DU, or email: [email protected]
You must reproduce our material accurately and not use it in a misleading context.
Page 12
Quality of leadership and management
Non-compliance identified at this inspection and action to be taken
Description of Non Compliance /
Action to be taken
The registered person must provide
CSSIW with evidence that the
recruitment and vetting of staff is fully
documented and demonstrates that the
recruitment and vetting procedure
contributes to the safeguarding and
promotion of service users’ welfare.
Timescale for
completion
31-May-2015
Regulation number
19 (2) (d) [i]
The service is not compliant with regulation 19(2) (d) of the Care Homes (Wales)
Regulations 2002.
This is because the registered person has not demonstrated that service users are
safeguarded through robust recruitment and vetting practice.
The evidence for this is that during our visit to the home on 10/04/15 there was a lack of
information and documentation available.
We asked to see the information and documentation available for staff recruited since the
last inspection. Five recruitment files were provided. Four of these files were not complete.
We were not provided with evidence to demonstrate that Disclosure and Barring Service
(DBS) certificates had been available prior to three of the staff members commencing work
at the home or that DBS Adult First barred list information had been sought.
The commencement date for one member of staff was shown as 20/01/15; a DBS
certificate was not issued until 29/01/15.
The commencement date for one member of staff was shown as 20/10/14; a DBS
certificate was not issued until 29/10/14.
The commencement date for one member of staff was shown as 21/10/14 a DBS certificate
was not issued until 26/10/14.
We found that written references were not available as required for three of the staff
members concerned. We were told by the registered person that references had not been
requested at the time of employment. We were told that references had recently been
requested but not yet returned. We were not presented with any documentary evidence of
this.
This evidence indicated that statutory checks to determine fitness are not fully completed
before allowing people to start working at the home.
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In addition to the above, we were told by the registered person that a DBS certificate had
not been sought for the fifth member of staff whose file we viewed due to a DBS certificate
having been issued for previous employment at the service. This employment had ended in
November 2012. The registered person had relied on the disclosure information being up to
date, including barred list information.
The impact for people using the service is that they have not been protected by the care
home’s recruitment practices and have been put at risk of suffering harm through the
appointment of possibly unsuitable staff.
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