Inspection on 28/08/08 for Welbourn Hall Nursing Home

This inspection was carried out on 28th August 2008.

CSCI found this care home to be providing an Adequate service.

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.

Other inspections for this house

Welbourn Hall Nursing Home 18/10/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Welbourn Hall Nursing Home Hall Lane Welbourn Lincoln Lincolnshire LN5 0NN Lead Inspector Dawn Podmore Unannounced Inspection 28th August 2008 09:30 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 Welbourn Hall Nursing Home DS0000070035.V370754.R02.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. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welbourn Hall Nursing Home Address Hall Lane Welbourn Lincoln Lincolnshire LN5 0NN 01400 272771 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) anne.ruttle@btconnect.com Nish Thakerar Post Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following category: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 40. 18th October 2007 Date of last inspection Brief Description of the Service: Wellborn Hall Nursing Home is a privately owned care home for older people. The home has been converted and extended from a former Victorian house. This provides residents’ accommodation on two floors with a passenger lift giving access to the first floor. The home has large gardens around the exterior of the home and a large car park for staff and visitors. The home is situated in the small village of Wellborn, which has a village shop and is on a bus route between Lincoln and Grantham. It provides accommodation for 40 people over the age of 65 who require either nursing care or personal care. There are 36 single rooms; and 2 shared rooms. The home provides a choice of dining areas and sitting areas including a large sunroom. At the time of the inspection the acting manager confirmed that the weekly fees ranged from £370 - £510 depending on the residents assessed needs. Additional charges are made for hairdressing, chiropody and newspapers. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available at the home. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced and took any previous information held by C.S.C.I. about the home into account. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they receive through the checking of records, discussions with them and the staff who care for them and observation of care practices. A partial tour of the home was also conducted which included looking at some bedrooms, communal areas, bathing and toilet facilities. Documentation was sampled and the care records of four residents were examined. We spoke with 11 residents and a relative, as well as five members of staff, including the acting manager Anne Ruttle. They shared their views about how the home operated on a day-to-day basis and the care and facilities provided. Prior to the visit the providers had returned an Annual Quality Assurance Assessment (AQAA) and this document will be mentioned throughout this report. We sent out some ‘have your say’ surveys to residents and staff however only one staff survey was returned in time to be included in this report. On the day of the visit 25 residents were living at the home. What the service does well: What has improved since the last inspection? Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 6 Medication records are completed more accurately so that staff receive clearer information and medications are administered safer. Care plans are updated regularly; this includes monthly evaluations and regular care reviews. The home has an improvement plan to upgrade the environment. Some communal areas and bedrooms have been redecorated and new furniture purchased. A new call bell system has also been fitted and laundry equipment purchased. What they could do better: Each resident needs to be consulted about his or her social interests, this information should then be included in person centred care plan which outlines how staff will support them to have the lifestyle they wish. This information can then be used to formulate a programme of activities that meets the needs of people currently living at the home. Recruitment practices must improve so that residents are protected from unsuitable people being employed. This needs to include a fully completed application form, appropriate references and a criminal records checks for all new staff before they start to work at the home. Although the home has a system in place to gain people views about their satisfaction with the service they are receiving it needs to be fully implemented. The provider needs to visit the home monthly and a produce a report of their findings. This will enable them to assess if the home is operating in a satisfactory way. The fire officer needs to be consulted about a safe way to keep doors in the home open so that people are not put at risk. The training programme must include specialist subjects such as conditions that affect older people. This will help to make sure that staff have the knowledge and skills to meet the needs of the people living at the home. Other areas that would benefit from some attention included the following. Care planning should be more person centred so that they contain more information about how people want their care providing. This will help to make sure that staff have a clear picture of people’s preferences and abilities, as well as their role in supporting each resident as an individual. People should sign their care plans to acknowledge that they have discussed how they want their care providing and agree with the planned care. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 7 Care plans should contain information about recent legislation that is designed to protect people’s rights and choices. The planned improvements to the environment including the repair to the roof, redecoration of the corridors and changes to the kitchen area should be completed as soon as possible. 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. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 8 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 Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 9 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): Standards 1 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure includes an initial assessment, which helps to make sure that the home can meet the needs of people admitted. EVIDENCE: A review of all information available prior to this visit, and the content of people care records, showed that the home does not admit residents without an assessment of their needs being completed. Although residents were unable to remember these taking place staff comments and records showed that someone had been visited them before they moved into the home. The assessment form does not however have space for the person completing it to sign it to show that they were responsible for its completion. The acting manager confirmed that although the home is registered with social services as being available to cater for people requiring intermediate care no one had been admitted for this care. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. Resident’s personal care and health needs are being met by staff who understand their needs and deliver care in a respectful manner. Care plans provide sufficient details to meet people’s needs, however they do not fully reflect peoples preferences. People are able to manage their medications themselves if they can, but if they need help staff are trained to support them with it in a safe way. EVIDENCE: We looked at the care records for 4 people living at the home, each with differing needs. They contained information about their main care requirements, but lacked detail about how people preferred their care to be delivered. Although social care plans were in place they did not provide enough information about what the residents wanted to do and how staff should support them. For example they contained standard statements such as ‘encourage to join in (activities)’ but did not say what their interests were. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 11 People could not remember being involved in the planning of their care, but staff said that this did happen. Two of the four files examined contained evidence of residents or their relative being involved in the planning while the others did not. Assessments for potential risk areas had been completed in topics such as, nutrition, pressure risk, falls and manual handling. This information had been incorporated into the care plans. A daily record of how people were progressing was being maintained and people’s care had been evaluated monthly. These had been improved since the last visit to contain better information about any changes in peoples care requirements. Annual care reviews had also taken place. The home has not yet included the content of the Mental Capacity Act in their care planning process. This is new legislation that is aimed at protecting people’s rights. People’s comments indicated that they were happy with the level of support provided as well as the way in which it was delivered. One person told us, ‘I am happy here, they are very good’ Records and peoples comments showed that residents had access to outside health professionals, such as their G.P, opticians and chiropodists. People’s health care was being monitored, which included monthly checks on their weight. Equipment such as hoists, air mattresses and bed rails were also in use. The provider’s Annual Quality Assurance Assessment (A.Q.A.A.) demonstrated that the home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. Records and a discussion with the nurse responsible for the morning medications showed that medications were being handled safely. People were appropriately dressed and looked well cared for. Observations showed that staff respected people’s dignity and encouraged them to make decisions about their daily lives. Staff were knowledgeable about what support people needed and how they preferred their care delivering. . Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The home enables residents to maintain and develop social interests and relationships of their choice, but care plan documentation does not reflect this. Residents receive a nutritious, varied diet, which meets their individual preferences and health requirements. EVIDENCE: Care records did not fully reflect peoples preferred lifestyle, but residents said that staff did support them to do what they wanted to do, when they wanted to do it. A social assessment form had been completed in all but one file, which gave some information about what activities people had enjoyed in the past. However this information had not been included in the care plans. Occasions when people had taken part in formal activities, or refused to do so, were recorded in a separate file. One record said that on numerous occasions the person had been unable to participate due to being in bed, but no alternative stimulation appeared to have been offered. The home has two people who are responsible for providing activities and stimulation for the residents. One works two days a week providing general activities. The other coordinator comes into the home three times a week to provide one to one stimulation and small group activities. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 13 The home had no activities programme to inform people what was available, but a few regular events, such as the hairdresser and chiropody visits were advertised on a notice board. The acting manager said that currently they are gathering information about people so that they can formulate a programme that meets people’s needs. Records and peoples comments demonstrated that residents had taken part in activities such as, bingo, musical therapy, manicures and games. They said that they had enjoyed the summer fete, which had had taken place 2 weeks ago, and there was a selection of books in one of the lounges. People’s comments included, ‘there’s not a lot to do, but it is adequate’, ‘I go to the hairdresser every week’ and ‘I enjoyed the music group that came yesterday and they are coming again soon’ People said that visitors and staff took them out for walks sometimes, but otherwise there were no organised outings. One person said, ‘I go out with my relative for the day’. They also told us that entertainers sometimes visited the home, which they enjoyed. Peoples religious needs were being met by a monthly visit from the local vicar and the manager said that access to other denominations was also possible if requested. The home has an open visiting policy and a relative told us that they were always made welcome when they visited. He told us, ‘staff are friendly and always give me a cup of coffee’. Lunch was served in the dining room or in people’s bedrooms. It looked appetising and well presented. Menus were displayed on the notice board and the manager said that one was provided to each resident. The acting manager said that for a small charge visitors could arrange to have a meal with residents at the home. People said that they were happy with the meals offered. One person said ‘lovely puddings’. Another resident who needed a special diet told us ‘I told them what I could eat and they made a menu round it for me’. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. Staff have received training in these subjects to help them protect the people they support. EVIDENCE: The home has a complaint procedure, which is displayed in the home and included in the Service Users Guide. Details contained in the AQAA and records held at the home, showed that they had received 2 complaints over the last year. Records showed that these had been appropriately investigated and recorded. Residents and visitors confirmed that they were aware of the procedure and would be comfortable highlighting any issues. One said, ‘I have no complaints at all’. The home has procedures concerning the protection of vulnerable adults. Staff demonstrated a satisfactory knowledge of what to do if they suspected abuse could be occurring. Although not all staff had received training about the types of abuse that might occur and the procedure for reporting any incidents, this subject had been including in their induction. A further training session had been arranged for November 2008. Welbourn Hall Nursing Home DS0000070035.V370754.R02.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable and homely environment, which offers a satisfactory standard of décor and furnishings, but some areas are in need of attention. EVIDENCE: We took a partial tour of the home, which included looking at the bedrooms of the residents we were case tracking. There were no unpleasant odours in the home and it was clean and tidy. One relative said ‘the home is always clean with no smells’. Bedrooms were personalised with small items of furniture, photos and mementos. Some areas had been redecorated since the last inspection and some new furniture purchased, but other areas were in need of attention. The kitchen is currently being expanded and refurbished to provide addition facilities. On the corridor outside the kitchen there was water damage from a leak in the roof. The manager said that the roof was to be repaired the Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 16 following week and the corridor repainted as part of the improvements to the kitchen. Other improvements to the environments and facilities provided included a new call bell system and stair gates being fitted to both staircases to provide added security. There is a designated hairdressing room where the visiting hairdresser provides a weekly service. The home was clean and tidy with a dedicated cleaning and laundry staff. Since the last inspection the laundry equipment had been replaced with industrial machines. A new sluice has also been fitted, but the flooring is damaged, the manager said that a new one was to be fitted shortly. Bathrooms and the shower room were homely and colourful with appropriate aids to help people get in and out of the bath. Other equipment was available including hoists, specialist beds and mattresses, bedrails with bumpers, raised toilet seat and grab rails. People said that they were happy with their rooms and the communal facilities. One person told us, ‘I’m happy with my room and the home in general’. The gardens and the car park were well maintained. Welbourn Hall Nursing Home DS0000070035.V370754.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. There is enough staff on duty to meet the needs of the people living at the home. The system for the recruitment of staff is not robust therefore it does not offer adequate protection for people living at the home. Staff have access to training and support to help them meet the needs of the people they care but specialist training is inadequate. EVIDENCE: Records and peoples comments indicated that there was enough staff on duty to meet the needs of the people currently living at the home. Staff spoken with told us that staffing levels were good at the moment due to the decline in the number of residents. They said that there was enough staff on duty to meet people’s needs. They told us, ‘we are given time to spend talking to residents, which is nice’, ‘there have been shortages in the past but currently levels are okay’ and ‘we use agency, but try to get the same people all the time for continuity’. Residents and relatives told us that staff were available when they needed assistance and that they were happy with how their care was delivered. One person commented, ‘they help me as needed’, and another said, ‘the carers are good and speak to you respectfully’. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 18 The home has a recruitment process that includes completing an application form, obtaining written references and a C.R.B. (Criminal Records Bureau) check. Recruitment records for 2 new staff were examined. The first contained an application form, written references and C.R.B. certificate. However there were gaps in the application form, such as their previous qualifications and jobs. The acting manager asked them to add the missing information during the inspection. Another file also had gaps in the application form. A full C.R.B had not been yet received, but the manager said that a P.O.V.A. (Protection of Vulnerable Adults) initial check had been undertaken and she was working with them as their mentor until the full C.R.B. came back (a C.R.B. from their last job was on file). However she could not find any evidence of the P.O.V.A. check being completed. The staff member was taken off the duty rota until a further POVA check was completed; the acting manager confirmed this, a week after the inspection. Three references were on one of the files, including one from their last employer. The other two were not on the homes form and were addressed ‘to whom it may concern’. The issues relating to accepting references not obtained directly from the referee were discussed with the manager. Records demonstrated that new staff receive a satisfactory induction to the home. Two new staff described how they were oriented to the home and received an awareness of the policies and procedures. One said that although they had previously worked at the home they were still given an induction. They both said that they felt that the support received was enough to prepare them for working at the home. Records and peoples comments showed that the company has a programme in place to ensure that staff received essential training. This included, manual handling, protection of vulnerable adults, infection control, health and safety and fire awareness. However records provided did not show that staff had received any specialist training, although in 2007 some people had undertaken dementia training. Planned training for the next few months included manual handling, food hygiene. Health and safety and abuse awareness, but no specialist training was indicated. Records and staff comments confirmed that out of 18 care staff 6 have completed an N.V.Q. (National Vocational Qualification) in care, and 5 are currently undertaking the award. Observation of care practices at the home demonstrated that staff were caring for people in an appropriate manner. Welbourn Hall Nursing Home DS0000070035.V370754.R02.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s management structure provides guidance and direction to staff to ensure that care is delivered in a consistent manner. A quality assurance system is in place, but it is not being used effectively to make sure that the home is managed in the best interests of the residents. EVIDENCE: The home has not had a registered manager for over 12 months. The acting manager has been in post for the last year, she is a qualified nurse with experience in running a care home. She told us in the AQAA that she has also completed her registered managers award. Residents and relatives told us that they were happy with the management of the home. One person said, ‘I am happy here, they are very good’. Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 20 Staff spoken with and those who returned surveys told us that they felt the home provided a safe and caring environment for people to live in. When asked about the management of the home one said, ‘the manager is approachable, her door is always open and she listens to you’. When asked what the home did well another person told us ‘team work’. One person said that the recruitment of more permanent staff would be beneficial. Another said that they could not think of anything that needed improving. The home has a quality assurance system so that it can gain the views of the people who use the service and make sure the home is operating correctly, but this was not being fully used. Minutes from the last residents meeting in April 2008 had discussed what activities people wanted to do. However there was no indication of which staff had been at the meeting or if people had been given the opportunity to discuss any other subjects. Although the manager was currently developing surveys to gain peoples views she said that none had been sent out during her time at the home. The provider or his representitive has to visit the home monthly and complete a report detailing their findings at the home and how any concerns or issues are to be addressed. Records showed that these visits had not been carried out on a regular basis. The content of the reports seen also lacked detail of how issues at the home were being dealt with and peoples views. The acting manager said that the home does not keep any monies in safe keeping for residents. Services such as hairdressing and chiropody had been invoiced directly to the resident or their representative if applicable. The home has a range of health and safety policies and procedures available to guide and instruct staff. There is a programme in place to service and maintain equipment in the home on a regular basis. Information provided in the AQAA, demonstrated that regular checks on equipment such as hoists and fire fighting equipment had taken place. A health and safety issue was raised during the inspection. Some doors were held open using wedges. The acting manager removed them and agreed to discuss their use with the fire officer. Welbourn Hall Nursing Home DS0000070035.V370754.R02.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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 3 Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement All residents must have a care plans identifying their social needs and how staff can meet these needs. This will enable staff to formulate an activities programme that meets people’s needs. Staff must be recruited using a robust system so that residents are protected from unsuitable people being employed. People’s views must be gained on a regular basis to ensure that the home is meeting their expectations. The training programme must include specialist subjects such as conditions that affect older people, to make sure that staff have the knowledge and skills to meet the needs of the people living at the home. The provider must make monthly visits to the home and a report produced recording their findings. This will enable them to assess if the home is operating in a satisfactory way. Timescale for action 03/11/08 2. OP29 19 25/09/08 3. OP33 24 01/12/08 4. OP30 18 03/11/08 5. OP37 26 30/09/08 Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 23 6. OP38 23 (4) (a) The fire officer must be contacted regarding the use of wedges to hold doors open to make sure that the home is not putting people at risk. 23/09/08 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 OP7 Good Practice Recommendations Care plans should provide better guidance to staff about people’s preferences and their role in supporting the residents. This will help to ensure that staff have access to clearer instruction about how people prefer to be supported. Residents and/or their relatives should be involved in the planning of care and sign the plans to acknowledge their agreement. This will help to make sure that they receive the support they need in the way they prefer. It is recommended that care plans include reference to the Mental Capacity Act, 2007 and the effects it has upon the service users lives. This is to ensure that their rights and choices are protected. 2. OP7 3. OP7 Welbourn Hall Nursing Home DS0000070035.V370754.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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