Inspection on 10/06/10 for Wellburn House

This is the latest available inspection report for this service, carried out on 10th June 2010.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wellburn House 02/06/09

Wellburn House 02/06/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 04/09/2010.

Random inspection report Care homes for older people Name: Address: Wellburn House Wellburn Road Fairfield Stockton-on-Tees TS19 7PP two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme 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 review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Jacqueline Herring Date: 1 0 0 6 2 0 1 0 Information about the care home Name of care home: Address: Wellburn House Wellburn Road Fairfield Stockton-on-Tees TS19 7PP 01642647400 01642647411 wellburn@schealthcare.co.uk www.southerncrosshealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Janice Mulloy Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross BC OpCo Ltd care home 90 Number of places (if applicable): Under 65 Over 65 0 90 dementia old age, not falling within any other category Conditions of registration: 90 0 The maximum number of service users who can be accommodated is: 90 The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 90 Dementia Code DE, maximum number of places 90 Date of last inspection 0 8 0 2 2 0 1 0 Care Homes for Older People Page 2 of 13 Brief description of the care home Wellburn House is a modern, purpose built facility that is registered to provide personal care to ninety older people. The home does not provide intermediate care. The first floor of the home has accommodation for forty-five older people with dementia and the ground floor has accommodation for forty-five older people receiving general personal care. All bedrooms on the first floor of the home are single in nature. There are forty-three single bedrooms and one large bedroom that can be used as a shared bedroom on the ground floor of the home. Bedrooms have en-suites facilities with a toilet and washbasin. The home is divided into three units. All rooms are comfortably furnished and residents may personalise their rooms. Bedrooms in the home environment meet space requirements of National Minimum Standards. There is an enclosed rear garden that has seating areas. Care Homes for Older People Page 3 of 13 What we found: This inspection was a random unannounced inspection. It took place on 10 June 2010 and was completed in one day by two compliance inspectors. The purpose of the inspection was to look at a range of matters that effect the care, welfare and wellbeing of people living at Wellburn House and also to follow up the requirements made at the pharmacy random inspection of 8 February 2010. During the visit we looked at a number of care records of people living at Wellburn House, medication administration records, menus and information about activities. We also looked at staff recruitment records, staff training records and staff supervision records. We also looked at some maintenance and servicing information along with quality assurance information. We had a look around the home, spoke with people living there and relatives who were visiting, we also spoke to staff and the manager. We also received a number of surveys from people living at Wellburn House and staff who work there. The care files of four people who live at Wellburn House were looked at, two from the dementia care unit and two from the older persons unit. Two of the care records were for people who had recently been admitted to the home. Care is needed when completed the pre admission assessment as in one of the records looked at these had been completed with very little additional information and none of the assessments scores had been totalled. The actual physical and social assessment were in the main well completed with additional individual comments. A range of additional risk assessment were in place, which had been updated monthly. There were additional risk assessments in place, such as for being at high risk of falls, these were individualised and there detailed additional actions. Care plans had been developed for areas of need identified through the assessment and risk assessment process. Staff need to be mindful of some of the interventions as in one care plans in respect of someone being at risk of falls, one of the interventions was, Staff to make sure X isnt left on his own due to unsteady gait. This person does not have one to one care. In one persons records they had a number of care plans for the same assessed needs, the old ones need to be discontinued and taken out of the file so that only the current care regimes are in place for staff to follow. Equipment such as pressure relieving cushions and airflow mattresses were in place where needs had been identified. One person had developed a pressure ulcer and there was insufficient information in their file regarding the development of this. The manager is investigating this. Some of the care plans could do with being more person centred, such as personal hygiene, working and playing and sleep pattern. In one persons care file an area of need Care Homes for Older People Page 4 of 13 had been identified for which there was no care plan, this related to their dementia and potential challenging behavior. Staff need to be mindful in respect of the cross referencing of information, for example in two of the plans of care for people, it states to weigh weekly, however only monthly weights were evidenced. There was clear evidence of input from GPs and district nurses and dietitians input where weight loss had been identified. Records for nutritional intake and turns charts are also being kept where there is a need. In one of the care records it was identified that this person needed to see a dentist, however there was no evidence that this had happened. One person had been seen by their Community Psychiatric Nurse who had requested certain actions, there was no evidence to show that these actions had taken place. People spoken to during the inspection were happy and settled at Wellburn House. The surveys also indictated this. People said, Looks after my needs well. Good Care. Very well looked after. Very happy, wouldnt like to go anywhere else. Vary happy with staff, feel safe in the home. During this random inspection medication systems were looked at on each of the units. Generally, the medication systems were good, with administration records being appropriately completed, medication balanced and good ordering procedures. It was however found that a number of creams had not been dated when they had been opened. Of nine items in current use only two items had the date of opening, items such as sudocrem, poly tar shampoo and canesten cream did not. Paracetamol used through the homely remedies system also were not dated when first opened. Two bottles of cough medicine used with the homely remedies system were also not dated when opened. One person who was taking Simple Linctus via home remedies had this written on their Medication Administration Record to take up to four times daily. This is not in accordance with the homely remedies procedure and this person should have been referred to the GP for this to be prescribed. There is a new manager in post, has been in post for seven weeks, it aware of issues with medication management and has said that it is one of his priority areas and has commenced some auditing and further staff training Two activities co-ordinators are employed and they arrange two activities every day. The activities currently include, beauty days, board games, quizzes, sing-a-longs, skittles and ball games. On the day of the inspection, a singer had been booked for the afternoon entertainment and people looked like they were enjoying this. The surveys received contained the following information about activities, Good entertainments, games and activities. Of what could be improved, people said, more trips out if possible, More outings. Whilst people have a social assessment in place, it is unclear how this is matched up with the activity plan. The records detailing individual activities could be improved as these are currently just a code. The menu was looked at, which is the standard Southern Cross menu., which is a four Care Homes for Older People Page 5 of 13 week rotational menu offering choice at each mealtime. People spoken to about the food said it was lovely. One person talked about enjoying their salad at tea time. Tables were nicely set in the dining rooms, with table cloths, napkins and condiments. The menus were also available on the tables. The complaints records were looked at. Complaints are being responded to although the formal complaints form is not always being used. There is however correspondence in place detailing the investigations that have taken place and outcome correspondence to the complainant. The last complaint recorded was 12/5/10 regarding the dining service. This was very well recorded, with corrective action being taken and satisfaction by the complainant. Training information was looked at and it showed that 82 of staff have received Protection of Vulnerable Adults training. There was also evidence of this training on staff files looked at and confirmation was also received through staff discussions. Wellburn House provides a warm and comfortable environment for people. There are now three distinct units within the home. The ground floor unit provides personal care for forty-five people. Upstairs there is a 15 bedded unit for people with dementia and a 30 bedded unit for people with dementia. We had a look around the home and a number of areas in need of improvement were identified. This included improvement to two of the bathrooms, which are currently out of use. There is the need to take swift action in regard to these areas as currently in one of the wings there are no bathing facilities in use. Bathrooms and shower rooms generally appeared tired and dated and the lighting in these areas was not good. The first floor dining room also needs to be improved as it currently does not provide a pleasing environment. The dining room furniture also needs to be replaced. The ground floor corridor carpet is worn and needs to be replaced and some repair is needed to the floor outside the administrators office. An action plan has been received from the manager detailing significant improvement that would be made to the environment including all of the above. This work is due to commence in the near future and should be completed by August 2010. The recruitment and training files of five staff were looked at, three of who were recently appointed staff. Good systems for recruitment were seen, with completed application forms, appropriate references and Criminal Records Bureau checks in place prior to commencement of employment. The induction process for the thee new staff had all been completed on one day, which is of concerns due to the amount that needs to be covered. Along with the three new staff files, we also looked at two established staff files for training and supervision purposes. These two staff had completed recent Mental Capacity Act and Deprivation of Liberties training. The was also evidence of Infection Control; Protection of Vulnerable Adults and medication training. 71 of staff are trained to NVQ Level 2 and 17 trained to NVQ Level 3. There has been some fairly recent training delivered by psychiatric liaison nurses in respect of challenging behaviour. 23 of staff are trained in dementia care. This number needs to be improved Care Homes for Older People Page 6 of 13 as half of the population of people living at Wellburn House suffer from dementia. It was confirmed that two members of staff have recently completed a dementia care course that now equips them to deliver training to other staff members. This training will be rolled out. The training matrix also shows that moving and handling training needs to be update. Staff were spoken to about staffing levels, they generally believed there was sufficient staff on duty to meet the needs of people living at Wellburn House. Without exception when staff were asked what they thought was good at Wellburn House they said that it was the staff team, they spoke of the support for each other and that they would go the extra mile for the residents. A new manager has been appointed and on the inspection visit had been in post for seven weeks. He has the required experience and knowledge to manage Wellburn House and he confirmed that he is in the process of registering with CQC. Staff said that since the appointment of the new manager, they were clearer about their roles, the home was more stable and he was very approachable, that he cares about the people living at the home and wants to be involved and kept informed. The records of regulation 26 visits were looked at. Reports were available for only six visits in the past 12 months. Visits had taken place for the last two months and the report format is now the new one in use with Southern Cross. They refer to action plans and reflect the actions being taken. There was also a Key Outcome Inspection report of March 2010, with an action plan in place showing the actions taken and confirmed completion of a number of these actions. The manager is also producing a monthly report and one was available for May 2010. Other quality assurance systems in place include among others, residents meeting, last conducted on 27/5/10 and very detailed information is minuted; staff meeting minutes 28/5/10, again good level of information and also monthly catering audits. There was also a file containing relatives surveys from February 2010. It is not clear if this had been transfered into a report format or if actions had been taken as a result of the surveys. Supervision records were looked at and it was shown that there had been gaps in supervision for example, one person had supervision August 2009 and not again until May 2010, this was similar for another staff member whose supervision records were looked at. There is the need to be mindful of the quality of individual staff supervisions as they had not really been individual, personal supervisions, more reminders of job role requirements. The recent supervisions looked at were much more personalised. What the care home does well: Wellburn House provides a warm and homely environment for people to live. People are pleased with the standard of care they receive and are happy with the food. People have opportunities to be involved in social and recreational activities, although they would like more outings. A good percentage of staff are trained to NVQ level 2 in care and staff spoke with knowledge about the needs of people living at Wellburn House. Staff themselves thought Care Homes for Older People Page 7 of 13 that one of the strengths at Wellburn House was the staff team who support each other well. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 13 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, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 9 of 13 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, 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 3 14 The pre admission assessment must be fully completed and must contain a good level of information. This will ensure that there is sufficient information to demonstrate that peoples needs can be met 23/07/2010 2 9 13 Systems must be in place to check expiry dates of medication and medication with a limited use once opened. This makes sure medication is safe to administer by reducing the risk of contamination. 23/07/2010 3 9 13 The management of homely remedies must be reviewed and staff must follow the correct procedure. This will ensure that people are provided with homely remedies in accordance with the procedure and have their medication reviewed if need 23/07/2010 Care Homes for Older People Page 10 of 13 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 be. 4 19 23 Improvements must be made to the environments, particulary the bathrooms, upstairs dining room and corridor carpets. The action plan submitted to CQC must be complied with. This will ensure that people live in a well maintained home. 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 27/08/2010 1 7 Staff should ensure that they cross reference information within the care records and ensure that the assessment and care plans are updated as a result. Work should continue in developing the care assessments and plans into more person centred ones. 2 8 Where needs have been identified that need the input from other health care professionals, there should be evidence that this has happened. When healthcare professionals have stated certain actions, these should be evidence to show that these actions have been addressed. 3 30 Staff should have the training they need to give them the information they need to safely meet the needs of people living at Wellburn House. The way in which the staff induction is delivered should be reviewed and needs to show that there is sufficient opportunity for the new staff member to fully understand their role in accordance with policies, procedures and care practice. Care Homes for Older People Page 11 of 13 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 4 33 Regulation 26 visits should take place on a monthly basis and a report should be available within the service. Staff should receive supervision at regular intervals and this should be personal to each staff member. Systems should be in place to ensure that staff continue to be updated with their mandatory training, including moving and handling and first aid. 5 6 36 38 Care Homes for Older People Page 12 of 13 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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