Inspection on 07/02/07 for Walldene Court

This inspection was carried out on 7th February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Walldene Court 28/02/08

Walldene Court 14/02/06

Walldene Court 13/06/05

Walldene Court 25/02/05

Walldene Court 16/07/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Walldene Court Threap Gardens off Simonside Avenue Howdon Wallsend NE28 7HT Lead Inspector Jackie Burke Key Unannounced Inspection 09:30 7 & 8th February 2007 th 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 Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 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. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walldene Court Address Threap Gardens off Simonside Avenue Howdon Wallsend NE28 7HT 0191 263 3791 0191 234 3313 tracey.clayton@anchor.org.uk www.anchor.org.uk Anchor Trust 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) Miss Tracey Armstrong Clayton Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (1) of places Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Walldene Court is a purpose built care home in Howden, which was opened in 1993. The home is based upon group living and consists of four units arranged over two floors. There are forty-two single rooms, all with en-suite facilities. Some local amenities are within walking distance and access in and out of the home is good. There are communal sitting rooms and dining areas on each floor and sufficient assisted bathing and toilet facilities around the home. There is a passenger lift in the centre of the building. Walldene Court provides nursing care and residential care. The costs of the service are £435- £497 per week Information, including inspection reports, is provided for service users to enable them to make a decision about moving to Cestria House. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two days on Wednesday 7th and Thursday 8th February 2007. Seven service users, three relatives and seven of the staff were spoken to. The records examined included, four care plans and medication records, and the records for complaints and accidents. Four staff files were also examined. What the service does well: What has improved since the last inspection? Bank accounts have been introduced to safeguard service users and their access to personal allowances. Recruitment is underway to fill staff vacancies. Uniforms and name badges have been introduced within Walldene Court to enable service users and visitors to recognise staff and to request support. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 6 What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 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 Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good Service users needs are assessed before moving into Walldene Court and identified needs are met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were looked at and contained detailed pre-admission assessments, which follows the model of activities of daily living. Needs assessments identify specific care needs for individuals. Specialist equipment assessments are made and equipment provided for service users with complex physical needs prior to admission. There are a high number of service users within Walldene Court who require mobility equipment. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10 Quality in this outcome area is good. Service users needs are set out in a plan of care so that staff have the information they need to provide care. Health care needs are met in full. Walldene Court has a satisfactory policy for dealing with medication, which safeguards service users. Residents are treated with respect and privacy is safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence that all areas of care are assessed in the care plans and that arrangements are in place to meet the needs of service users. Evidence was available to show that care plans are updated and there is an audit system in place. Care plan formats are due to change within the Anchor Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 10 group in the near future; the manager anticipates that this will improve care plans. Care plans include likes and dislikes regarding food and individual preferences regarding activities and pastimes. There are risk assessments in place, which are detailed and regularly updated to take into account changing needs. There is evidence of specialist support for service users i.e. wheelchair services, physiotherapists and occupational therapists and other health and social care professionals. There is a good level of information in care files about residents’ care needs. Evidence from records and discussion with staff was available to confirm that residents’ health care needs are assessed and met. Appropriate assessment tools are used to assess heath care needs including pressure areas and nutrition. Falls risk assessments are in place. The home has policies and procedures in place to ensure the safe administration of medicines. The treatment room was clean and well organised. Evidence was available from observation during the inspection that staff respond to service users with respect knocking on doors before entering and speaking appropriately to people who live in Walldene Court. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15. Quality in this outcome area is good. Walldene Court provides a good standard and variety of activities, which means that there is a stimulating environment for service users. Links with families, friends and the community are encouraged. People are enabled to exercise choice in their lives. People are provided with a balanced diet and meal routines are provided flexibly wherever possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans include information on individual likes and dislikes and preferences, which are used when planning activities and pastimes. This shows that individual choices are taken into account when providing care and support in Walldene Court. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 12 Activities are currently provided in Walldene Court by care staff, there is an activities coordinator in post for 20 hrs per week however the post holder is on sick leave. Activities are logged in the diary in the office and show that people are supported to engage in activities with friends and family and in house events are organised where possible. Staff and service users recently enjoyed “Burns Night “ and Christmas and festive buffets. Birthdays are marked by a buffet tea and birthday cake celebration for each service user. Visitors were seen to come and go freely during both inspection visits and visitors and service users spoken to confirm that they were made welcome when they come to Walldene Court. Tea and coffee facilities are provided in each of the dining rooms for service users and visitors to help themselves. Service users are encouraged to maintain control of their money and there is a SMART bank account system, which operates in Walldene Court to enable people to do so. People are encouraged to bring items of furniture and personal possessions to Walldene Court and individuals rooms showed evidence of this. Service users said that they could choose where they liked to spend their time and what pastimes they wished to engage in. People said that they could choose when they preferred to have a bath or a shower and that staff would provide them with support to do so. Menus have been reviewed and changed within Walldene Court and the cook is knowledgeable in diet and nutrition for people with a variety of dietary needs and has taken a proactive approach to meal preparation within the home. Meals are cooked freshly on the premises each day, homemade soups are provided and cakes and biscuits are baked regularly. The kitchen provides meals for people who require special diets and kitchen staff are skilled in their use of liquidised foods and moulds. As a result attractive nutritious food is presented to all service users to promote and encourage a good diet. Dietary supplements are available for service users who have been assessed as requiring them. The kitchen is well equipped and cleaning routines are in place. Service users said that they were satisfied with the quality and quantity of food available and that staff know their likes and dislikes. Dining rooms are clean and pleasant and well presented with clean tablecloths, napkins and condiments available at meal times. Fresh chilled juice is available in communal dining rooms in addition to tea and coffee making facilities and a fridge & toaster. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. There is a complaints policy in place and service users complaints are dealt with appropriately. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy in place within Walldene Court and service users and family members spoken to showed that they were aware of the policy and who to direct their complaints to should they have any. There have been two complaints in the past twelve months and evidence showed that both had been dealt with appropriately following the complaints procedure. There is a whistle blowing policy at Walldene Court and most staff have been provided with training in the protection of vulnerable adults. Staff spoken to were aware of the need to protect vulnerable adults and were clear about what they would do if they had any concerns about the care of people living in the Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 14 home. Staff members have demonstrated that they uphold the safety and wellbeing of service users in their care. Recruitment policies and procedures within the home are robust. Staff files checked contained Criminal Record Bureau checks and written references as well as checks to cross-reference and confirm each individual applicant’s identity. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 & 26 Quality in this outcome area is good Service users live in a home, which is comfortably furnished safe and well maintained. There are sufficient W.C. & washing facilities. The home is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Walldene Court is purpose built and is well maintained with ongoing refurbishment and redecoration taking place as necessary. Chairs have recently been replaced in the sitting rooms and the local authority environmental services were booked to collect surplus furniture from the home during the week in which inspection took place. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 16 Service users bedrooms are personalised reflecting individual choices and preferences. Service users spoken to said they were happy with the decoration of their bedrooms and that they were kept clean by staff. There are four communal bathrooms one of which is a combined shower and bathroom and one communal shower room within Walldene Court. The communal shower room on the first floor requires refurbishment. The bathroom on the ground floor is due to be updated. In addition two service users bedrooms have shower rooms attached. The sluices were tidy, clean and odour free and the disinfectors operational. Staff were observed to follow infection control policies throughout the day. The laundry is well organised with wheeled racks and individual baskets for clean clothing. The equipment consists of appropriate numbers of commercial type washing machines and dryers. The home is clean and odour free and appears light and airy with wide corridors, which provide ease of access for service users who use wheelchairs. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is good Appropriate numbers of staff are provided and there are qualified nurses on duty to meet the needs of service users. Service users are in safe hands and are supported and protected by recruitment policies and practices. Staff are provided with training however shortfalls identified should be addressed as a priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing rotas show that the Manager ensures that enough staff are on duty to meet the needs of the residents. There are 10 nurses working at Walldene Court; 31 care staff and 11 ancillary staff. The records examined for recruitment and selection were complete and files well organised. Application forms were completed in detail and the records included two references, Criminal Records Bureau checks are undertaken prior to appointment and Protection of Vulnerable Adults list checks are made to Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 18 safeguard the well being of service users. The Manager has a system to ensure that the qualified nurses are up to date with their NMC registration. The training programme is extensive and includes statutory and clinical training including Dementia care; back care coordinators training, palliative care and continence management. However a significant number of staff continue to require Protection of Vulnerable Adult Training and Moving and Handling training updates. These shortfalls should be addressed as a matter of priority within Walldene Court. 18 care staff hold NVQ level 2 at Walldene Court. The manager is nearing completion of her Registered Managers Award. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 & 38. Quality in this outcome area is good Service users live in a home which is managed by a person of good character, who is fit to be in charge The home is run in the best interests of service users. Service users financial interests are safeguarded. Staff are not provided with formal supervision on a regular basis. The health safety and welfare of service users and staff are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 20 The manager has been in post since November 2004 and has worked at Walldene Court since 2001. There is a strong management team at Walldene Court, which ensures that operational systems are effectively maintained. Each service user has a bank account and money can be transferred to ensure enough funds are available for personal use. Audits of the money are carried out at regular intervals. Formal staff supervision has not been provided on a regular basis within Walldene Court and records show that staff are provided with supervision less often than is recommended. The manager is aware of the importance of supervision for staff. As a demonstration of commitment toward addressing this area of practice she has developed a new programme of staff supervision and anticipates that staff will be provided with supervision at appropriate intervals. Informal supervision is provided to staff and regular staff meetings are held to discuss practice issues. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP30 Regulation 13 (5) Timescale for action The staff must all receive moving 30/04/07 and handling training updates as planned. Outstanding Requirement 14 February 2006 Identified staff must receive 30/04/07 POVA training The staff supervision programme 30/04/07 must be undertaken as planned. Outstanding Requirement 14 February 2006 Requirement 2. 2. OP30 OP36 18 c (i) 18 (2) 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. Refer to Standard OP12 Good Practice Recommendations Routines of daily living and activities should be maintained which are flexible and varied and meet the expectation and preferences of service users. Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Walldene Court DS0000028822.V325096.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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