Inspection on 13/02/06 for 3 Welholme Road Care Home

This inspection was carried out on 13th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Welholme Road Care Home 12/03/09

3 Welholme Road Care Home 25/03/08

3 Welholme Road Care Home 22/01/07

3 Welholme Road Care Home 27/10/05

3 Welholme Road Care Home 21/02/05

3 Welholme Road Care Home 20/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 3 Welholme Road Care Home 3 Welholme Road Grimsby North East Lincs DN32 0DY Lead Inspector Stephen Robertshaw Unannounced Inspection 13th February 2006 09:30 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 3 Welholme Road Care Home Address 3 Welholme Road Grimsby North East Lincs DN32 0DY 01472 359574 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Prime Life Limited Michelle Elizabeth Holliday Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Physical disability (8) of places 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/10/05 Brief Description of the Service: 3 Welholme Road is a care home that is registered to provide personal care and accommodation for up to 16 service users with a mental disorder (excluding learning disability or dementia), 8 of whom may also have a physical disability. Prime Life Ltd owns the home. The home is on a main bus route to the centre of Grimsby and overlooks People’s Park. It is in keeping with other properties in the area and has large enclosed gardens with a car parking area. Accommodation is based on two floors. All bedrooms are for single occupancy. A passenger lift offers disabled access from the main house to bedrooms situated on a lower level corridor. Further bedrooms are provided on the first floor. Bathrooms and toilets are provided on both ground and first floors. There is a range of communal areas including two lounges, dining room, and a service users’ kitchen. The home is comfortably furnished and is domestic in character. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information for this report was gathered through an inspection of the home on 13th February 2006. The inspection was unannounced and was over a seven-hour period. The inspector looked at the written records in the home interviewed management and staff and spoke to the service users. The staff and service users were mostly very positive in their attitude towards the home. What the service does well: The service users have their needs assessed before they are admitted in to the home and they state that they are ‘well looked after’ by the staff. The individual care plans were developed through the service users assessed needs. The care plans had been evaluated on a regular basis. Where appropriate and needed the care plans are supported by risk assessments and risk management plans. Regular service user meetings are held and they are recorded. These support how the service users opinions are listened to at the home. The service users are supported to access services and activities in the community. The service users also stated that the activities available in the home had improved in frequency and diversity. The home maintains good communication with the service users healthcare workers that are based in the community. The home does not provide nursing care. Good contact is also supported between the service users and their families and friends. A tour of the premises found it to be free of any offensive smells and policies and procedures were in place to control infection. All prospective new staff to the home have appropriate POVA first and/or CRB clearances before they have any contact with the service users. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 6 Staff receive regular formal supervision to ensure that they can meet the needs of the service users. The manager of the home has achieved the Registered Managers Award and is close to completing NVQ 4 in care. The management approach to the home is open and inclusive. What has improved since the last inspection? What they could do better: The home should have a copy of the company’s up to date policies and procedures in position and available to the service users and the staff group. The shower room ceiling must be repaired with some urgency. The registered person must develop an effective quality assurance and monitoring system. The registered person must provide information that supports that the electrical systems in the home are safe. The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ2 or equivalent. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 The service users are provided with the opportunity to determine how their needs will be met at the home. EVIDENCE: There were thirteen service users living at the home at the time of the inspection and the inspector observed all of the case file information in relation to two of the service users. The service users care plans showed that their needs could be met at the home. Staff training records showed that the staff receive all of the mandatory training that is required by regulation and specialist training in relation to the needs of service users with mental health problems. This ensures that they can meet the needs of the service users. One of the care files for a service user did not include the terms and conditions of their residency at the home. The other file did include terms and conditions of their residency and this included all of the information required by national minimum standard 5.1. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8 and 9 The service users needs that are identified through their assessments are met by the home. EVIDENCE: The inspector observed the care plans for two of the service users. These both included plans to meet the assessed needs of the service users. Where appropriate these were also supported by risk assessments. The care plans had all been evaluated on a minimum of a monthly basis to ensure that the service users needs remained the same and were being met. It was also identified that if individual needs changed then new care plans were develop to meet them. The service users involved were also in agreement to their care plans. The inspector observed the records of service user meetings held at the home. These had been undertaken on a regular basis. The service users confirmed to the inspector that the meetings had taken place and that at the meetings their opinions and views were listened to. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 11 The meetings showed how the service users were consulted in relation to the choice of meals at the home and activities provided at the home. Service users also stated to the inspector that the staff consulted them to gain their opinions in relation to different aspects of the services that are provided by the home. The confidential information stored in the home was held in accordance with the Data Protection Act 1998. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 The service users at the home are provided with the opportunity to develop their personal lifestyles and independent skills that were identified through their individual assessment of need and care plans. EVIDENCE: The service users case files seen by the inspector included information of the contact that the service users had with their family and friends. The contact was also recorded in the individual service users daily diary entries. Service users stated to the inspector that they received ‘good support from the staff’ to maintain their relationships with their family and friends outside of the home. It was identified in service users care plans if there were any restrictions in their movement and in these occasions the care plans were also supported through risk assessment and risk management plans. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 13 Designated areas of the home are set aside for service users to smoke in and all of the service users spoken to by the staff were aware of the restrictions for smoking in the home. The care staff provide the meals at the home as there is not a cook employed there. The service users stated that they are generally happy with the quality of the meals that are provided for them. Discussions with the service users supported that they are consulted in relation to what they would like to include on the homes menus. Direct observation at a mealtime by the inspector showed that the meal times are not rushed and alternative meals are provided for service users that do not want the option that is provided by the main menu. The meal times were also observed to be very flexible to meet the needs of the individual service users. Service users stated that they always receive ample amounts of food and that extra food is available if they require it. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The service users personal and healthcare needs are met at the home. EVIDENCE: The home does not provide nursing care. Service users care files observed by the inspector supported the evidence that healthcare professional based in the community support the home with the healthcare needs of the service users. Healthcare support is provided to the service users through services including GP’s, psychiatrists and community nurses. Individual care plans identified the professional supporting the health care of the service users and any contact that they had with them. The care plans also identified where service users required support or encouragement to maintain their personal hygiene. Individual care plans observed by the inspector all included an assessment of the service users nutritional requirements. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The adult protection policies and procedures in the home supports the welfare of the service users. EVIDENCE: Since the last inspection there had been no formal complaints registered at the home or with the Commission in relation to the services provided through the home. The homes complaints procedure is made available to the service users and visitors at different areas around the home. The home had a copy of ‘No Secrets’. When the company revised this document all the staff signed to say that they had read it in October 2005. The homes policies and procedures including the protection of vulnerable adults were dated November 2004. Following the last inspection report the Responsible Individual met with representatives of the Commission and stated that the home had a policy and procedure document that was issued in April 2005. In spite of this assurance a copy of this document was not available at the home at this inspection. There is still an on-going adult protection investigation in the home. Since the last inspection there has been no further movement on the investigation. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,28,29 and 30 The service users feel that the environment provided at the home is improving. EVIDENCE: The service users were positive in relation to their environment and stated that it was beginning to be improved. A second handrail has been fitted to the ramp provided for wheelchair users to aid their mobility. The service users stated that this was a slight improvement but they found the ramp to be too steep to use safely, adding that they pick up considerable speed in their wheelchairs when going down the slope. The service users stated that they were happy with their individual rooms and said that they are able to say how their rooms are decorated. A programme has begun in the home to redecorate service users bedrooms and to include new carpets and furniture where they are required. A service user complained to the inspector in relation to the condition of the communal bathrooms and toilets. However a tour of the premises before the inspection began and during the course of the inspection found all of the 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 17 homes toilets and bathrooms to be clean, hygienic and were free of any offensive smells. One of the shower room’s ceilings had collapsed. This was not recorded in the maintenance book. The maintenance man stated that he was waiting for another maintenance worker to help him to replace the ceiling, as he could not do this by himself. The manager and the maintenance man agreed that this was urgent matter that should to be dealt with and gave assurances to the inspector that this work would be completed within a very short time scale. The smoking room of the home has recently been redecorated. This room was much more appealing to the service users and they stated to the inspector that they were ‘much happier’ now that the room had been decorated. The paintwork in the corridors had been ‘touched up’ to cover damaged paintwork however this just stood out against the remainder of the paintwork which still requires renewing. The homes washing machines are programmable to disinfection and sluicing standards. There is a choice of shared spaces in the home that the service users can choice to use to sit and spend time with their peers, family and friends. A tour of the premises supported that the home is free of any offensive smells. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 The employment procedures for new staff at the home now ensures the safety of the service users. EVIDENCE: The manage and staff interviewed by the inspector confirmed that the staff receive clear job description before they commence employment at the home and that they had a clear understanding on their own roles and responsibilities and those of their colleagues. The management and staff have a positive attitude towards NVQ training however they have not yet achieved 50 of the care staff to have achieved NVQ 2 or equivalent. The NVQ training is provided through an external agency. The staff and assessors are so committed to completing the training that the assessor also visits the home on Saturdays to make sure that all of the staff undertaking the awards have access to the assessor. Staff training records supported that they receive training specific to the needs of service users with mental health problems. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 19 The staff personnel records evidenced that all prospective new staff to the home now receive appropriate security vetting to ensure that they are safe to work with the service users group and that their welfare is maintained. The staff records also showed that the home received two written references for all new staff and that equal opportunities were followed in the employment of staff. There were no staff working in the home that were under twenty-one years of age. Staff interviewed by the inspector confirmed that they undertake induction and foundation training to the sector skills workforce training targets. The inspector also observed and induction training package for a new member of staff. Since the last inspection the staff supervision records showed that the staff are now receiving regular recorded supervision periods. The staff interviewed stated that their supervision covered the care plans that they were working to, the philosophy of care provided in the home and their personal training needs. The manager of the home stated that new staff to the home are supervised on a more regular basis than the general staff group to allow them to develop and support them in their new role. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42 and 43 The management of the home is open and accessible to both the service users and the staff groups. EVIDENCE: The manager of the home has completed the Registered Managers Award and is close to completing the NVQ 4 in care. She stated that this will be completed probably before April 2006. Service users and staff stated to the inspector that the manager was very approachable and was always available when she was in the home. There was no evidence in the home that it has an effective quality assurance and monitoring system. The inspector informed the manager that it was a priority that this should be developed so that the home can gather other peoples views and opinions on the services that it provides. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 21 The home had copies of the companies policies and procedures however these were not the companies most recent policies and procedures and therefore the staff did not have the knowledge of them and could not work to the companies up to date policies and procedures. The external management of the home visit the home on a regular basis to undertake regulation 26 visits. The records of the visits were available in the home. The records documented in the home were all stored in accordance with the Data Protection Act 1998. The staff records of all of the service users daily activities were more clearly recorded. The majority of the homes health and safety requirements were met however the home still does not have a safety certificate for the electrical systems in the home. This is an outstanding requirement. The registered person must contact their insurance company and obtain confirmation that their insurance will not be nullified if they do not hold the appropriate electrical safety certificate. Unless indicated through a comprehensive risk assessment the radiators in the home must be provided with low temperature surfaces, or be guarded to protect the service users from possible burns. The current risk assessment identifies that there could be a risk to service users but does nothing to reduce the risks. The external management complete a monthly audit of the homes finances and develops action plans for the maintenance of the home in conjunction with the homes manager. The external management of the home do not ensure that the home is kept up to date with the company’s policies and procedures. The manager has recently been supplied with a new computer to support her with the homes finances. The homes insurance was up to date and met the needs of the service. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 1 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 3 1 2 3 1 2 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 23 Regulation 12 Requirement The registered person must ensure that all staff are aware of the homes updated policies and procedures in relation to the protection of vulnerable adults. Requirement for 30/11/05 was not met. The registered person must ensure that the shower room ceiling is replaced. The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent. The registered person must ensure that the home has an effective quality assurance and monitoring system. The registered person must ensure that the home has an up to date certificate confirming the safety of the electrical systems, or a letter of confirmation from their insurance company that this is not required. Requirement for 27/11/05 was not met. Timescale for action 17/03/06 2 3 YA27 YA32 16 18 13/03/06 01/06/06 4 YA39 24 01/07/06 5 YA42 23 17/03/06 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA5 YA24 YA40 Good Practice Recommendations The registered person should ensure that all of the service users have a copy of their terms and conditions of residency at the home. The registered person should ensure that the redecoration of the premises is completed to improve the environment. The registered person should ensure that the home is supplied with the companies up to date policies and procedures. 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 3 Welholme Road Care Home DS0000002819.V272067.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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