This inspection was carried out on 17th November 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Elizabeth Welsh House Pennine Way Harraby Carlisle Cumbria CA1 3QD Lead Inspector
Paula Banham Unannounced Inspection 17 November 2005 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Elizabeth Welsh House Address Pennine Way Harraby Carlisle Cumbria CA1 3QD 01228 606394 01228 606401 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) Cumbria Care Miss Evelyn Marion Nelson Care Home 40 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (40) of places Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The service must at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of forty (OP40) older people may be accommodated, Eight (8) of whom may have dementia (DE/E). The staffing levels for the home must meet the Residential Forum Care Staffing Formula for Older Adults by 1st April 2004. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 27th June 2005 Date of last inspection Brief Description of the Service: Elizabeth Welsh House is a care home registered with the Commission for Social Care Inspection to provide personal care and accommodation for up to forty residents. The home provides permanent accommodation for residents and short term intermediate care to assist people to regain their independence and return to their own homes. Elizabeth Welsh House is owned and carried on by Cumbria Care which is a Cumbria County Council business unit. Mrs Evelyn Nelson is employed as the registered manager of the home. The home is located in a residential area on the outskirts of Carlisle. The home is close to local shops and services and on transport routes into the city centre. The property consists of a purpose built two storey building set in its own grounds. Accommodation is provided as forty single bedrooms, four of which have ensuite facilities. There are accessible toilet and bathing facilities close to all the accommodation used by residents. Shared space is provided in the form of three sitting/dining rooms, a separate smoking room and a large, comfortable entrance hall. The layout of the home meets the needs of the residents living there. The home provides pleasant outdoor areas with seating for residents. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on 17th November 2005. The inspection focussed on how well the care provided in the home meets the needs of the residents living there. This was assessed by speaking to residents, visitors and staff, observing activity in the home and examining the records held. What the service does well: What has improved since the last inspection? What they could do better:
The home provides a high standard of care and all of the standards assessed at the inspection were met. There were no areas identified as requiring action. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 6 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. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. The home has a good procedure for handling new admissions and residents know that the services provided will meet their needs. EVIDENCE: Residents’ needs are assessed before they are offered accommodation in the home to ensure that the services and facilities are suitable to provide the support they need. The home’s admissions procedure includes a review of each resident’s needs once they have settled in the home. During the review residents are able to give their views of the home and care provided and to decide whether they wish to continue living there. Residents and their families made many positive comments about the home and said, “We couldn’t have chosen anywhere better”. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 10. Residents are provided with a high standard of care which meets their needs and respects their privacy and dignity. EVIDENCE: The home provides a high standard of care which meets residents’ personal and health care needs. Residents are supported by local GP practices and have access to routine health care from dentists, opticians and chiropodists. Care staff observe residents and take appropriate advice and actions if they are concerned about an individual’s health or well being. Residents are treated with respect and their privacy and dignity are protected in the home. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14. Residents maintain control of their lives and the decisions they make are respected. EVIDENCE: Residents choose who they see in the home and they maintain contact with their families and friends as they wish. Visitors said they were made welcome by staff in the home. Residents continue to make decisions about their lives including who they see and where they spend their time. Care is provided in a manner which respects residents’ rights and independence. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents and their families know how to raise concerns and that complaints will be handled properly. EVIDENCE: The home has a clear complaints procedure which is included in the information given to people when they move into the home. Residents are confident voicing concerns and know that action will be taken to resolve any problems. Residents said that the manager meets with them regularly and said, “Evelyn wants to know if something’s not right”. Residents and visitors in the home said they have “no complaints at all”. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26. Accommodation for residents is clean and well maintained and provides a pleasant environment to live in. EVIDENCE: The home provides comfortable and homely accommodation for residents to live in. The premises are clean and are decorated to a high standard. Residents choose whether to spend time in their own rooms or in one of the communal sitting rooms. The home has a maintenance plan which ensures that areas requiring attention are identified and work carried out in a timely manner. The smoking room has been redecorated and new flooring has been provided. The room is now hygienic and more pleasant for people to use. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 29. Residents are protected by the home’s recruitment and training procedures. EVIDENCE: New staff are recruited using Cumbria Care’s recruitment procedures which include taking up of references and Criminal Record Bureau and Protection of Vulnerable Adults list disclosures. The procedures ensure that staff are suitable to work with residents and to maintain their safety. New staff undertake thorough training to give them the skills to provide a high standard of care. Care staff receive regular training to update their skills and knowledge to ensure they are able to meet residents’ needs. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 38. The home is well run and residents’ rights, interests and welfare are protected. EVIDENCE: The management team in Elizabeth Welsh House are committed to providing a high standard of care. The atmosphere in the home is welcoming and relaxed. Residents are confident with the staff who support them. Procedures are in place to ensure that the home provides a safe environment for residents to live in. Care staff receive regular training to give them the skills and knowledge to carry out their duties safely. Good procedures are followed where valuables are held for safekeeping and residents’ interests are protected. Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X X 3 Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 16 NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elizabeth Welsh House DS0000035205.V257685.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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