Inspection on 17/12/07 for Welbeck House

This inspection was carried out on 17th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Welbeck House 10/06/09

Welbeck House 09/06/08

Welbeck House 25/09/06

Welbeck House 14/11/05

Welbeck House 20/10/04

Welbeck House 25/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Welbeck House 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS Lead Inspector Rebecca Harrison Key Unannounced Inspection 17th December 2007 09:30 Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 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 Welbeck House DS0000030055.V356620.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 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. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welbeck House Address 42 Welbeck Avenue Bushbury Wolverhampton West Midlands WV10 9LS 01902 681909 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) Arcare (West Midlands) Ltd vacant post Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Welbeck House is registered with the Commission for Social Care Inspection to provide accommodation and care for a maximum of three adults with a learning disability. Arcare (West Midlands) Limited is the registered provider and the responsible individual is Dr Raj Sharma. The post of registered manager is currently vacant however an acting manager was appointed on 12th November 2007 and is in the process of applying for registration. The property is a traditional semi-detached house and is situated in an urban area of Bushbury, providing access to local amenities and transport and the premises are in keeping with the local community. Accommodation is provided over two floors comprising: Two single bedrooms and a bathroom on the first floor and one single bedroom with en-suite on the ground floor. Communal space includes a kitchen, lounge and dining room. The home has a small garden to the rear of the property. The homes stated philosophy is to Maintain a high standard of care, respecting individuality, privacy, residents dignity and independence at all times. First and foremost a happy and secure environment within the home. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged range from £430.00 - £512.00 per person per week. This information should be included in the Service User Guide as required; therefore the reader may wish to obtain this information direct from the service provider. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The provider was given less than one hours notice of this inspection to enable access to the home as the service is not staffed at all times. The inspection took place on 17th December 2007 by one inspector over five and a half hours. A range of evidence was used to make judgements about this service to include a tour of the home, discussions with a member of staff, acting manager, area manager, responsible individual, former registered manager and a relative. The inspector also looked at a number of records to include care records for two people and observed aspects of care provided for one person who was present at the home during the inspection. In preparation for the inspection we received eight surveys from people using the service, relatives and staff and some of their comments have been included in this report. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to Welbeck House for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale, which they did and some of their comments are included within this inspection report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and any others considered appropriate and to review the requirements made as a result of a random inspection undertaken in February 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The staff team appear committed to the people they support and work positively within the resources available. Some of the comments that we received include: ‘The staff at Welbeck are very caring, I think the staff care about the service users as their own…they are looked after very well. I am just happy my relative is in a friendly, good clean home with the help of managers and staff’. ‘Day to day care’. ‘X is happy at Welbeck and does not wish to live anywhere else’. ‘Good staffing, and caring for service users welfare’ Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 6 ‘Gives the service users a nice home to live in’. ‘The care of the residents is very good. The residents seem very happy and contented’. What has improved since the last inspection? What they could do better: We found some serious areas of concern in the homes recruitment practices, which potentially placed the people using the service at risk. We requested that the provider take urgent action to address the shortfalls in order to safeguard people using the service. No new staff should provide direct care to service users without all pre-recruitment checks being undertaken. Throughout the inspection the area manager fully acknowledged the shortfalls across the service to include poor recruitment practices, care planning, risk management, record keeping and policies and procedures. She intends to address these at her earliest opportunity. The provider must ensure each individual has a detailed support plan and a behaviour management plan for individuals whose behaviours may challenge. This will ensure staff are provided with the necessary information to support people in a consistent and effective manner. People are enabled to take risks however identified risks should be assessed and kept under review. Staff should develop a greater understanding of empowering the people they support. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 7 Records are not easily accessible however the area manager intends to improve current systems to make these more readily accessible. Some of the comments that we received include: ‘They could manage the running of the home much better, like offering good quality food, good comm. with manager and staff. The owner of the home needs to take more interest. Poor maintenance of the home...they don’t listen to staff when you report anything’. ‘I would like to meet my manager on a more regular basis to discuss the changing needs of service users and suggest means and ways to improve their likes more meaningful and staff alike’. ‘Information is being passed on to staff and manager but there are times when it is passed on second hand, which is watered down, delayed and has no bearing’ ‘In this multicultural society we must treat each service user as an individual and therefore aim to meet their needs respecting their rights such as their preferences, culture and choice. I would like to be able to offer service users a wide variety of meals, allowing them to choose’. ‘Health and safety is one of the key factors that govern the health sector and if not in place then we would be defeating our objectives and I would like to see the maintenance of the premises improve’. ‘Food could be better and more choice offered. More outings for service users’ ‘The filing needs to be updated and modernised. New furnishings need to be bought and residents need to go out more. Following the inspection we received written correspondence from the Responsible Individual stating ‘We note your concerns and confirm measures will be taken to safeguard policies and procedures. The safety of our service users is a paramount importance….The area manager has been engaged to provide additional management support and bring in line procedural practices, including recruitment, She will liaise with CSCI to meet all regulatory requirements’. 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. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 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 Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are provided with the information needed to decide whether this service will meet their assessed needs. They are given the opportunity to visit the home and are provided with a contract, which tells them about the service they will receive. EVIDENCE: The home has a Statement of Purpose available however this requires updating to reflect the new organisational structure, management and staff qualifications. People have access to a Service User Guide. The area manager committed to updating the guide to comply with the changes in the Care Home Regulations as amended in September 2006. Since the last inspection one person has been discharged as the home were unable to meet the persons needs due to his presenting behaviours. One person has recently been admitted to the home following an assessment of his needs undertaken by the placing authority. It was reported that a manager visited the person at his day service placement however no completed record of formal assessment was undertaken by the provider. The area manager reported that this would be addressed for all future admissions to the service. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 10 It was reported that the person visited the home prior to admission but no outcome of these visits were available. A member of staff spoken with reported that the person has settled into his new home well and is developing good relationships with his peers and staff. A signed copy of his contract was available outlining the service agreed however the fee charges was not stated and it was not signed by the service user, their representative or the provider. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staff are not provided with sufficient information to ensure they are able to meet peoples individual needs, aspirations or to enable them to achieve their personal goals. People are supported to make decisions about their lives and enabled to take some responsible risks however identified risks must be assessed and regularly reviewed to ensure people are fully safeguarded. EVIDENCE: Records held on behalf of the person most recently admitted to the service and one existing service user was examined. The provider had obtained needs assessment from the placing authority for the person most recently admitted however failed to develop a support plan generated from the assessment covering all aspects of personal, social support and healthcare needs as required. Managers present acknowledged this shortfall at the time of the inspection. A member of staff spoken with stated ‘He is independent and Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 12 doesn’t require much help’. The assessment seen stated the person ‘requires help with some aspects of personal care and daily living needs’. Given staff are lone workers staff are clearly not provided with the necessary information to ensure consistency of support ensuring his assessed needs are fulfilled. Records evidence that a review was held within two weeks of the person’s admission and was attended by the service user, social worker and three staff. A support plan and assessment of risk was available on the file of the other person case tracked however these records had not been reviewed and updated to reflect his change in needs following a period of being admitted to hospital and requiring rehabilitation in a nursing home. Records seen and discussions held indicate that one person’s behaviours are presenting challenges to the service as observed during the inspection however no behaviour management plan has been established to support staff with managing the challenges positively and consistently. Records indicate that some staff have expressed concern with supporting the person when lone working. It was reported that one person has been referred for independent advocacy services as recommended by the last key inspection. Another person has regular contact with his relatives who advocate in his best interests. During the inspection a relative telephoned the home to speak with the inspector and share compliments about the service. One survey received from a service user indicated that he ‘sometimes’ makes decisions. Discussions held with the area manager indicate that she has started to address this in relation to involving people in choosing new colour schemes for their bedrooms, menus and choice of where food is purchased. Assessments to support a service user to take responsible risks were available on one of the files examined but not on the person most recently admitted. This potentially places the individual at risk given that the assessment clearly stated that he is at risk of exploitation and intimidation. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are provided with some educational and social activity and are supported to keep in contact with their family and friends. People are more actively involved in menu planning and receive a varied diet in accordance with their dietary needs. EVIDENCE: All three people access external day provision. Two people attend day services throughout the week with one of these people travelling independently. The third person is slowly being reintroduced to his day service two days per week following a period of ill health and therefore remains at home supported by staff the remainder of the week. Daily records seen evidence that people access the community and partake in some activity. It was reported that a referral had been made to Occupational Therapy for an assessment of daily living skills. The acting manager reported Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 14 that she intends to further develop activities, which was highlighted as an area that requires improvement in one of the surveys we received. Discussions held with a relative during the inspection and surveys completed by two relatives indicate that they are kept up to date concerning important issues. One relative stated ‘I am always kept informed by a member of staff what is happening at Welbeck…I can go and see my relative at any time or speak to him on the phone and he comes down to my house at weekends… I am kept well informed… I have peace of mind that X is kept safe and well’. Observations made on arrival at the home evidence that routines are flexible which was also evidenced in daily records examined on behalf of two people. The area manager acknowledged that more could be done to involve service users with daily living tasks and promoting their independence. It was reported that people have very recently been provided with greater opportunity to choose and plan menus and where they wish to purchase food. A greater variety of branded food was seen available in addition to fresh vegetables. A record of meals eaten was recorded in daily records that suggest that people are provided with a balanced diet taking into account their dietary needs. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff are not provided with sufficient information to satisfactorily meet the health needs of all the individuals accommodated. The home has a system of handling, storing and managing medication that safeguard the people who use the service. EVIDENCE: As previously stated a support plan had yet to be developed on the person admitted to the service in October 2007. Therefore lone staff are not provided with information regarding the persons preferences about how he wishes to be supported to ensure lone staff are consistent in their approach. Daily records indicate that routines are generally flexible. It was recommended at the last key and random inspection that support plans be further developed in relation to the level of assistance an individual requires in undertaking personal care tasks but this has yet to be addressed. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 16 Records evidence that people access NHS Healthcare facilities and appointments are recorded. The area manager is to introduce a more in depth recording health tool to include outcomes of health appointments. It was reported that one person has been referred to Occupational Therapy for an assessment. Observations made and daily records held on behalf of one individual suggest that the person is showing signs and symptoms of a health condition requiring specialist input. The area manager fully acknowledged this and committed to seeking advice at the earliest opportunity. Medication procedures appeared satisfactory at the time of the inspection. Procedures were discussed with the acting manager who demonstrated a good understanding of how medication is managed. Managers were advised to store prescribed ointments requiring refrigeration in a lockable storage tin, as these are currently accessible to all. Two people are on prescribed medicines and staff have received training in the safe handling of medicines and the monitored dosage system. Medication Administration Records were found satisfactorily recorded as required by the previous key inspection. The area manager has agreed to review and update the homes medicines policy and to assess ongoing staff competency to administer medicines. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Procedures to safeguard service users from potential abuse are in place but require further development. Staff are provided with the necessary training in adult protection to ensure they have the knowledge and an awareness of the referral process to safeguard the people using the service. EVIDENCE: The service has a complaints procedure held with the complaints record. This has been reviewed and generally meets the national minimum standards however the area manager intends to make the policy more service user friendly and readily accessible. A survey completed on behalf of a service user demonstrates that he has an understanding of whom to approach if he had concerns about the service although surveys received suggest not all relatives do. No complaints were found recorded in the complaints book. We have not received any complaints about this service in the last twelve months however in November 2007 we did receive a concern about the management of home, quality of food, poor recruitment procedures and poor furnishings. Staff have received adult protection training. The area manager agreed to obtain a copy of the revised safeguarding adults policy and procedure. No individuals have been referred under safeguarding procedures since the last Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 18 inspection. Training certificates evidence that staff have received training in dealing with violent incidents since the last inspection. Financial procedures were discussed with the acting manager and recording systems examined. It was reported that the social worker is still addressing finances for the person most recently admitted therefore the home are currently lending him money and recording this. The acting manager was advised to obtain two signatures against entries. It was reported that monies are being restricted in his best interests however a protocol should be developed in conjunction with the service user and others for this. Although staff considered that procedures safeguard the people who use the service, a policy should be developed for the management of finances to ensure staff are clear about service users expenditure to include meals out, transport costs etc. One person is presenting behaviours that challenge the service, which has led to the acting manager being called out to the home on two occasions over the last couple of weekends. Records indicate that not all staff are confident in supporting the person when lone working. The area manager agreed to address this in addition to seeking specialist advice at the earliest convenience as behaviours may be as a result of an underlying health condition. Staff should log all incidents and monitor outcomes and ensure they are supporting the person in a consistent manner. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements have been made to the environment to provide the people who use the service with a homely, clean and comfortable place to live. EVIDENCE: A full tour of home was undertaken accompanied by the acting manager. Since the last inspection the house has been repainted externally and a ramp fitted to the front of the property to aid access. Both the dining room and lounge have been redecorated and a new lounge suite purchased. It was reported that colours schemes have been discussed with people using the service and that bedrooms are to be redecorated and people provided with co-ordinated bed linen. One room was being redecorated at the time of the inspection. Old furniture in two rooms has been replaced and rooms found personalised. The area manager has been issued with a budget and discussions held with her clearly evidence that improving the environment across all three of the provider’s services is now a priority. The bathroom is to be refurbished in the New Year as required by the previous key inspection. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 20 The home was generally found clean on the day of this unannounced inspecton. Training certificates evidence that staff have received training in infection control procedures. Substances hazardous to health were appropriately stored and the necessary assessments in place. Liquid soap, paper towels and rubber gloves were not readily available in all areas requiring them and a safe system for disposing continence products should be addressed. Staff records evidence that staff have previously raised issues concerning the lack of personal protective equipment in the home. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a trained and committed staff team however poor recruitment practices and lack of structured induction have potentially placed people at risk of harm or abuse. EVIDENCE: Throughout the inspection managers and a member of staff were seen to interact positively with the one person being supported at home. Of the three support staff employed one holds a nationally recognised care qualification known as NVQ at levels 2 and 3. It was reported the other two support staff are to commence their award in January 2008 as confirmed by a member of staff. A relative spoken with during the inspection was very complimentary about the staff team and stated ‘The staff at Welbeck are very caring people’. The team at Welbeck House consists of a manager, one senior support worker and two support staff. The staff rota was examined. The area manager is looking into revising staff rotas to include full names, contracted hours and positions and reviewing staff working long shifts and in excess of their contracted hours. The usual staffing ratio is one member of staff supporting Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 22 three service users. Surveys received suggest that staffing levels are sufficient to meet the assessed needs of the people accommodated however staff records seen indicate a couple of people have expressed concerns about the behaviours of one person. The area manager reported that she intends to review staffing levels from 18/12/07 given the increased needs of one person and recent events. Since the last inspection one person has been recruited. The self –assessment (AQAA) completed by the provider states ‘Service users are safeguarded by the homes recruitment and policy practices and all staff are CRB checked’. Records for the person who commenced duties on 12/11/07 were not readily accessible at the home therefore the area manager agreed to collect the personnel file from the main office in Wolverhampton. These records were examined and clearly evidenced significant shortfalls in documentation as required by Regulations and evidenced that the Company does not operate a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The position was not advertised, no application form had been completed, only one reference was available addressed ‘To whom it may concern’, with no address from the person supplying the reference. There was no reference from the person’s last employer, no health statement and no valid Criminal Record Bureau or POVA checks, although it was stated that a CRB had been applied for. The person confirmed that she had not received induction to the required specification and the rota indicated that the person shadowed a member of staff for just two shifts prior to working alone directly with service users. The person was on duty at the time of the inspection. The provider was requested to take urgent action to address the shortfalls in order to safeguard people using the service and a letter requiring urgent action was sent to the provider within 24 hours of the inspection. Surveys received from three staff indicate that they are provided with good training opportunities relevant to their job as confirmed in discussions with a member of staff and the training records seen. Since the last inspection staff have attended training in moving and handling, lone working, dealing with violent incidents and infection control procedures. Not all staff have received training in first aid. It was reported that a staff training and development plan had been developed as required by the previous key inspection however this was not available for inspection. Staff records examined and staff surveys received evidence that staff are in receipt of formal supervision with a line manager but not at the required frequency. One person stated ‘I would like to meet my manager on a more regular basis to discuss the changing needs of service users and suggest means and ways to improve their likes more meaningful and staff alike.’ Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The service has not been managed in the best interests of people using the service potentially placing people at risk. Senior managers have a clear understanding of the areas in which the service needs to improve to benefit people using the service. Quality assurance processes are underdeveloped. Outcomes for people using the service are not evaluated to bring about improvements. Health and safety arrangements are generally satisfactory however assessments to support risk taking and safe working practices need to be further developed to safeguard people using the service and the staff group. EVIDENCE: Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 24 Our Regional Registration Team received notification from the registered manager on 26th November 2007 stating she no longer wishes to be registered for this service and has submitted an application to become the registered manager of a sister home. A new manager commenced duties on 12th November 2007 and was present for part of this inspection supported by the new area manager. It was stated that the manager is in the process of applying for registration. Discussions indicated that the new manager has made some changes and appears liked by the team. The self assessment (AQAA) completed by the provider states ‘Residents benefit from competent management…that the home has no outstanding requirements …records are well presented and maintained’. The overall findings of this inspection clearly evidence that this service has not been managed in the best interests of service users. The staff team have lacked direction and leadership and service users interests have not been safeguarded as evidenced by poor or non-existent record keeping potentially placing people at risk. The area manager fully acknowledged the shortfalls found during this inspection and is aware that a number of requirements previously made remain outstanding. She demonstrated a clear commitment to change, to improve overall outcomes for people using the service and to meet the requirements that have not previously been met for example visits and reports required under Regulation 26, the refurbishment of the first floor bathroom and record keeping systems. Surveys to gain the views of people using the service, their relatives and stakeholders have yet to be distributed however the area manager committed to undertake this in the new year in addition to the visits and reports required under Regulation 26. The service has produced a basic annual development plan as required by the previous key inspection. The area manager intends to further develop this. As identified throughout this report records required by regulation for the protection of service users and for the effective and efficient running of the home were not in good order or not available for inspection. Records examined evidence that health and safety checks are carried out at the required frequency however water temperatures have not been tested for two weeks as the thermometer has broken. Assessments to support risk taking and for safe working practices to include radiators require further development, which the area manager committed to doing. A risk assessment to support staff lone working has been developed as required. It was reported that neither the Fire or Environmental Departments have visited the home since the last key inspection however managers reported that they intend to contact the fire officer shortly to discuss current fire safety arrangements. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 25 Records indicate that staff have attended training in safe working practices however some require first aid training. The area manager reported that it is intention to introduce monthly safety checks and agreed to follow up the issue identified on the electrical hardwiring certificate and to ensure a copy of the revised health and safety policy is readily available. Staff have been provided with moving and handling training to effectively support one individual as required by the previous inspection. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 x 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 1 x 1 x 1 2 x Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(1)(2) Requirement Timescale for action 01/01/08 2 YA9 13 (4)(b) 3 YA34 19 4 YA35 18 (1) (c) Each individual must have a detailed support plan in place covering all aspects of their personal, social and healthcare needs to ensure staff are provided with sufficient information to effectively support the assessed and changing needs of service users. Identified risks must be 01/01/08 assessed and regularly reviewed to ensure service users are not placed at risk of harm or neglect. All pre-recruitment checks 17/12/07 to include CRB, two written references, health statement must be obtained before new staff commence direct work in order to protect people from possible harm. All staff employed must 31/01/08 receive training appropriate to the work they are to perform to include structured induction in line Skills for Care specification. Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 28 5 YA39 24(1) 6 YA41 17 Quality assurance and monitoring systems need to be developed to measure the homes success, assist with planning for the future and contribute to person centred care. Requirement not met since 31/12/06 The quality of record keeping must be improved to ensure that all information required by regulation is accessible, kept up to date and accurately reflects individual needs to ensure people are not placed at risk of harm. 31/01/08 17/12/07 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 YA18 Good Practice Recommendations Support plans should clearly indicate the level of assistance an individual requires in undertaking personal care tasks to ensure staff have sufficient information to effectively support individuals. A policy for the management of finances should be developed at the earliest opportunity to ensure staff are fully informed of the procedures for dealing with peoples finances. Arrangements should be made to ensure that all staff receive formal supervision at the required frequency to ensure they are provided with the necessary support they need to carry out their jobs. An application to register an experienced and competent manager with CSCI should be undertaken at the earliest opportunity. Mandatory training for all staff should be kept up to date supporting the safety of service users. 2 YA23 3 YA36 4 5 YA37 YA42 Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Welbeck House DS0000030055.V356620.R01.S.doc Version 5.2 Page 30 - 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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