Inspection on 11/04/06 for Welbourn Manor

This inspection was carried out on 11th April 2006.

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

Welbourn Manor 10/04/07

Welbourn Manor 21/11/05

Welbourn Manor 16/06/05

Welbourn Manor 01/02/05

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Welbourn Manor High Street Welbourn Lincoln LN5 0NH Lead Inspector Moya Dennis Key Unannounced Inspection 11th April 2006 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 Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Welbourn Manor Address High Street Welbourn Lincoln LN5 0NH 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) 01400 272221 Guardian Care Homes (UK) Limited Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability over 65 years of age (1), Mental of places disorder, excluding learning disability or dementia (1), Old age, not falling within any other category (31) Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old age, not falling within any other category (OP) 31. Dementia, over 65 years of age (DE(E) (4) on a named basis only. Mental Disorder, under 65 years (MD) (1) on a named basis only. Learning Disability (LD)(E) (1) on a named basis only. The maximum number of service users to be accommodated is 31. 2. Date of last inspection 21st November 2005 Brief Description of the Service: The house dates from mediaeval times and was originally a large, country, manor house, enclosed in mature and attractive gardens, one area of which is enclosed, accessible and safe for the residents to use. It is a Grade 1 listed building so any alterations or adaptations to the inside or outside require local council authority. It is situated in the centre of the village of Welbourn, which is between Lincoln and Grantham and has good road and public transport links to both. The home is owned and run by Guardian Care Homes UK Ltd. The care home is registered to provide personal care, not nursing care, for up to thirty-one people of both sexes over 65 years. The home can also provide care for up to four named people with dementia needs and one named person who is under 65 years of age. Seventeen residents are accommodated in single rooms and there are six double bedrooms on the ground and upper floors, with access to the upstairs by passenger lift. The home has no en suite facilities. There are four communal bathrooms and eight toilets. Parking is available at the front of the building. Fees range between £318 and £420 per week. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information regarding all inspection records and information about Welbourn Manor provided by the manager The inspection was unannounced and took place over 6 hours. The deputy manager was present at the start of the inspection; the acting manager was present after the first 30 minutes and remained throughout. The inspection included a full tour of the building, conversations with residents and one visitor, looking at information on care plans and files, interviews with staff and case tracking of 4 residents. This involved tracking care these residents received through examining records, discussions with them and care staff and observation of care practices. What the service does well: What has improved since the last inspection? Since the last inspection the home has appointed a new Activities Co-ordinator, working 12 hours per week, and provides more imaginative and creative activities for residents. Redecoration plans for individual rooms have already commenced, rooms being redecorated as they are vacated Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 6 Staff training has improved and 8 staff are taking, or have, NVQ awards. The office administrator and acting manager have improved recording processes and most of the requirements left at the last inspection have been met. 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. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. Prospective residents and their families are given appropriate information to make informed choices about the home. Residents’ needs are fully assessed before they are admitted. EVIDENCE: Every resident is given a copy of terms and conditions, detailing what is provided under contract by the home. This includes level of fees, when they are paid and by whom. Residents are given a choice of rooms whenever possible and the room number quoted in the contract. Services carrying additional fees, such as hairdressing, chiropody or toiletries, are also detailed. All residents have an eight-week trial period. Prospective residents are able to visit the home to look round before deciding to move there and if this is not possible, relatives or other supporters can do so on their behalf. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 9 Before moving to the home all prospective residents are visited by the acting manager to assess their needs. Family members, the service user, community health workers, hospital staff, GPs, social workers and anyone else the service user wishes to be involved are all invited to contribute to the assessment to give as full a picture as possible. Copies of recent social work assessments are also kept in residents’ personal files. A visitor said, “Staff always make me feel welcome and I know I can have a cup of tea whenever I ask”. Full handovers take place at every shift change and any concerns or notable changes are fully discussed, helping to ensure continuity and consistency of care for residents. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. Care plans fully document the needs of residents. Residents’ health care needs are by local health services. Robust medication policies are in place. Residents are treated with respect at all times. EVIDENCE: Individual care plans give details of health and social needs, nutritional assessments, appropriate risk assessments, family contacts and social histories. Relevant information given by other professionals is also kept in residents’ files. Care plans are reviewed regularly but some were not signed by residents or relatives to indicate their input or agreement. The home does not provide nursing care so community nurses visit residents as necessary. They also supply any specialist equipment needed, such as pressure relieving mattresses and cushions. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 11 The acting manager has improved the system for ordering, storing and administration of medication. All records examined were clear, signed, and only current medication was stored. Only staff who have received appropriate training administer medication. No residents choose to self-medicate at present. Care staff were seen using a diversional approach with confused residents, showing insight to their particular anxieties. Issues of incontinence were addressed in a discreet manner. Staff always knocked on residents’ door and waited for a reply before they went in. During the tour of the building, the manager was seen to have a good rapport with residents. One commented, “She’s lovely and we always a have a laugh”. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. A new employed activities co-ordinator has been employed for 12 hours a week, providing a wide range of leisure opportunities. Residents exercise choice to participate in organised activities and religious events and maintain links with the local community. Visitors are made welcome. Residents enjoy a varied diet and meals are taken in pleasant surroundings. EVIDENCE: A new activities co-ordinator has been in post for a few weeks and has been very creative in offering more varied and meaningful activities. After consulting with residents about choice and preferences the co-ordinator devised a programme that includes knitting, sewing, card making, communal games and baking. Residents with disabilities and varying levels of understanding have been included in the programme, reflecting awareness of equity and diversity. The co-ordinator identified residents’ strengths to maximise inclusion and improve a sense of self worth. The home held an Easter Fayre recently, which was reported, in the local newspaper. Residents were making Easter cards at Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 13 the time of inspection and had made a wide selection of goods for sale at the next public event. The residents spoken to, male and female, all remarked on the difference the activities have made to their daily lives and all wanted more activity time a week. Regular services are held at the home and one resident attends church with the help of church members. The garden parties and sales are to be a regular event and the next one was being planned at the time of inspection. Menus sampled gave wide choices for breakfast, including a ‘full English’ every day; 2 choices were given for lunch and a selection of light meals for tea. One soft diet meal had been individually pureed to make it look as appetising as possible. The dining room is pleasantly homely, clean and tables are laid café style complete with cloths. One resident and their visitor remarked on the good laundry service, remarking, “nothing had ever gone missing, nothing had been spoiled and clothes were always returned looking nice.” Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. Relatives are aware of complaints procedure. Staff are trained and confident in recognising and reporting abuse issues. EVIDENCE: Only one visitor was present at the time of inspection. They said that they would feel confident in discussing any concerns or complaints with the staff. They were confident that any issues raised would be acted on appropriately but said, “there has never been any need to complain, the staff try so hard”. There had been a recent complaint from a resident’s relative. Correct procedure had been followed and the complaint handled appropriately. All residents spoken to said they would feel able to raise any concerns with staff or management. They said the acting manager was very approachable. Residents are offered postal votes at elections. Staff were seen giving residents their personal mail, unopened. Staff have received appropriate training and spoke confidently about adult abuse issues. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. The quality of this area is poor. This judgement has been made from evidence gathered during inspection, which included a visit to the service. There has been general improvement in the environment of the home overall but the bathrooms and toilets are inadequate and do not comply with standards. EVIDENCE: The recently fitted wooden laminate flooring gives communal areas an attractive, bright appearance. New carpets have been laid in corridors and most bedrooms. Residents are able to use the enclosed gardens in warmer weather, with easy access and level surfaces. Since the last inspection, bathrooms and toilets remain in the same poor state of repair, in need of new fittings and decoration. Toilets are old and some are Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 16 cramped but all were clean and odour free at the time of inspection. Three bathrooms are shabby, uncomfortable for residents to use and difficult for staff to work in. The fourth bathroom is unusable as it lacks hot water. All staff on duty remarked that they hated working in the bathrooms and would be ashamed to show them to prospective residents or visitors. All residents spoken to said they disliked using them. Two residents said, “They let the place down”. The bath hoists available do not meet the needs of every resident and take no account of people who prefer to shower. One bathroom has a ‘walk in’ bath but staff say that this is little used. Individual room sizes vary; some are large enough to take pieces of furniture from residents’ previous homes, some are limited to smaller items and photographs. All the rooms seen were clean and homely. At the time of inspection the standard of cleanliness throughout the home was good. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. All staff receive regular training and are committed to provide a high standard of care. Residents are protected by a robust recruitment policy. EVIDENCE: Three care staff support the acting manager, who is not included in the shift. Catering, administration, domestic and maintenance staff are also employed. Three staff members interviewed have had training in dementia, health and safety, moving and handling, fire safety and adult protection in the last 6 months. One had had additional training in drug administration and two had had training in infection control. There is a National Vocational Qualification, (NVQ) training programme for staff. Of the three staff member interviewed, one has NVQ 3, one NVQ 2 and the third, being new to post, is currently studying for NVQ 1. Staff files inspected showed that correct recruitment procedures are followed. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38. The quality of this area is good. This judgement has been made from evidence gathered during inspection, which included a visit to the service. Morale has improved within the home and the acting manager has fostered good working relationships with other professionals. Staff received regular formal supervision. Recording processes are satisfactory. EVIDENCE: The acting manager has been in post for 6 months, and is currently applying to the Commission to be registered as manager. Staff report a much better atmosphere, saying the acting manager is approachable and willing to listen to Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 19 other points of view. Shift patterns have been changed and are now regular, which enables staff to keep a reasonable work/life balance. Staff meetings are held monthly and minutes were provided for inspection. Staff said that any issues they raised were always dealt with. Personal allowance records of residents were sampled. Monies held tallied with records in all cases. All withdrawals are countersigned. Only the acting manager or senior carers have access to personal allowances. Staff receive formal supervision sessions every twelve weeks. Fire procedures are posted on the wall; the fire alarm is tested weekly and emergency lighting monthly. Both systems were tested during the inspection. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 20 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 3 3 3 3 3 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 3 18 3 2 3 2 2 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 21 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 OP21 Regulation 23(2) Requirement Bathroom facilities must meet the needs of residents and must be kept in a good state of repair. This requirement remains outstanding from the last inspection. Timescale for action 30/06/06 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 When care plans are drawn up or reviewed, they should be signed by the resident whenever possible, or their relative or representative, to evidence user involvement. Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Welbourn Manor DS0000061236.V289077.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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