Inspection on 16/06/05 for Welbourn Manor

This inspection was carried out on 16th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/04/06

Welbourn Manor 21/11/05

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 Vanessa Gent Unannounced 16 June 2005 10.00 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 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 C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Welbourn Manor Address High Street Welbourn Lincoln LN5 0NH 01400 272221 01400 272210 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Guardian Care Homes (UK) Limited Mrs Karin Enright Care Home 31 Category(ies) of Mental Disorder (MD) - 1 registration, with number Old Age (OP) - 30 of places Dementia over 65 (DE(E) - 4 Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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) (30) 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 The maximum number of service users to be accommodated is 31. Date of last inspection 01/02/05 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 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. No bedrooms have their own bathrooms or toilets. There are four communal bathrooms and eight toilets. Parking is available at the front of the building. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took eight hours. The main method of inspection used is called case-tracking which involves selecting a proportion of residents and tracking the care they receive through the checking of records, discussion with them, the care staff and observation of care practices. Two residents were case-tracked and their records checked. At least four residents and two relatives spoke with the inspector. Eleven comment cards were received from residents and relatives. One from a relative was “more than satisfied with the care” provided and all but two ticked to say they were satisfied with the care given. All felt welcomed into the home by manager and staff. One expressed concerns over the care given to a particular resident; one was concerned about a resident’s personal expenditures. The inspector spoken with two staff: their files were checked and found to be in order. All people involved with the home wish the term resident to be used rather than service user. What the service does well: What has improved since the last inspection? A statement of purpose and service user guide has been created which relates specifically to the home and is comprehensive. The manager now only admits residents who fit into the category for which the home is registered. Reporting to the Commission of Social Care Inspection (CSCI) on the appropriate forms when untoward incidents or accidents occur has improved since the last inspection. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 6 A person has been appointed to manage the home, although he has yet to apply to register as manager. The acting manager has worked at the home for three months and has already made improvements and changes. Chemicals used for cleaning, that were found at the last inspection, are now stored safely. 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 C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3 Measures are in place that ensure that residents are able to make an informed decision before choosing to live in the home and are assessed to ensure that the home can accept them and can meet their needs. EVIDENCE: The statement of purpose and service user guide now adequately describe the services the home can and does provide. The statement of purpose was on display and a copy of the service user guide is given to each new resident on admission. The acting manager visits the prospective resident in their previous environment and completes a pre-admission assessment to ensure that the home can meet the needs of all residents that are admitted to the home. Preadmission assessments and an initial assessment were seen in the care plans examined. Community care assessments from placing social workers are used as a basis for the creation of care plans and were seen in one of the care plans examined. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 The healthcare needs of the residents are not always identified which can result in insufficient liaison with healthcare professionals to monitor and treat residents with health care concerns. Medication facilities mean that residents are at risk of harm. EVIDENCE: A new care plan format has been introduced which staff originally found difficult to complete but are now finding easier. Two staff spoken with feel confident to complete the care plans but few staff have been trained in how to write care plans effectively and appropriately. Two residents’ files were examined. Both were care plans from the previous system. Neither was comprehensively completed to ensure the needs of the residents are met. The front information sheet was well-completed but several other sheets on each care plans were not completed. No evidence of involvement of residents or relatives was seen in the creation or review of care plans. The manager stated that there are no residents with skin care concerns although a comment card states that a resident has a tissue viability problem which has not been actively treated. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 10 The husband of a resident who has been seen by the physiotherapist and needs regular walking exercise, states that his wife only gets five minutes walking exercise each day with staff which is not improving her weight-bearing and mobility. The district nurse visits to attend to a resident with healthcare needs. Medicines are stored and administered from a small cupboard with barely enough space for adequate storage, situated in a busy corridor. The person administering the medications is frequently interrupted to allow residents and staff to pass along the corridor. Staff find it intolerable and distracting. The trolley is also inadequate as it requires staff to bend frequently and is barely big enough to contain the medicines. Training has been recently undertaken by staff who administer medications. No resident administers his or her own medications. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 Insufficient activities mean that residents are not stimulated and do not have their needs and wishes met. Meals are appetising, varied and offer a balanced diet. EVIDENCE: No activities organiser is employed at present. The manager says that staff do activities with the residents. Residents and relatives feel there is not enough going on to keep them occupied. “Residents just sit in chairs all day”. Food is said to be “excellent”, “good, tasty, OK”. The meal served during the inspection was hot and fresh ingredients were used. It was colourful and appeared appetising, nutritious and balanced. Those requiring assistance were treated with respect, carers being seated, wearing disposable aprons and facing the residents. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16, 18 The complaints policy is adequate to enable residents and relatives to feel confident to use it. Unless staff are trained in abuse awareness, residents may be at risk of harm. EVIDENCE: A Complaints policy is displayed in the hall. Two complaints have been received by the home over the past twelve months, one partly upheld and one not substantiated. Both were responded to within the recommended timescale. Only five staff out of 21 have received adult abuse awareness training. A recent visitor to the home observed poor practice and on reporting it, the manager, took appropriate action to safeguard the residents. One relative stated anonymously in a comment card that a resident feels “stressed, unhappy and scared of getting on the wrong side of staff”. No other resident or relative confirmed these feelings. Most residents spoken with say that staff are “good, lovely”, “nice, friendly”, “pleasant”. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 21, 24, 25, 26 Requirements which were made at the previous inspection have not been acted upon to provide residents with a comfortable, homely and pleasant environment. The home does not ensure that residents feel that their surroundings suit their tastes and keep them safe. EVIDENCE: Although a programme of re-decoration and refurbishment has been commenced in some communal areas and bedrooms, there is no maintenance plan to show how and when the company intends to complete this and no contractors work at the home on a regular basis. The bathrooms are still not comfortable or homely to use. Residents’ bedrooms are personalised although some feel that furniture has been placed in rooms without consultation with the occupant or their representative that is not required and may be a hazard to safe moving and handling of the resident. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 14 Some relatives say that the housekeeping staff are not on duty every day and the home is not cleaned at these times. A person is employed to do maintenance. Records kept by him are clear, dated and signed on completion. All annual maintenance contracts have been completed. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 30 There are insufficient staff on duty to meet the needs of all the residents safely. The home does not provide enough training to ensure that the residents are kept safe from the risk of harm and that their needs are met. EVIDENCE: An insufficient number of staff are on duty to meet the needs of the residents the sprawling layout of the building and the dependency levels of the residents have not been taken into account. It is felt by relatives and some staff that there are not enough staff on duty to keep the residents safe at all times. Three of the eleven comment cards received did not believe that there are enough staff on duty. It was stated that “staff are sometimes hard-pressed to cope”. The manager sees the levels of dependency of the current residents as lower than the staff say: staff feel under pressure and say they “can’t be everywhere at once. There is often no staff anywhere near the lounges, if someone needs help elsewhere.” The level of training undertaken by staff is poor, including the basics such as moving and handling, food hygiene, infection control, first aid, adult abuse awareness, health and safety, Control of Substances Hazardous to Health (COSHH) and care of people with dementia or challenging behaviour. This places the residents at risk of harm. Recent training for adult abuse awareness only lasted a couple of hours one afternoon, which all staff spoken with felt was inadequate. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 16 Six staff are undertaking their National Vocational Qualifications but they feel they are always too busy “on the floor” to complete them. When a carer is being assessed, there is no-one spare to work with the residents. Staff do not have a contract of employment. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 36, 38 The acting manager has put improvements into effect in the home which protect the residents from risk of harm. Record-keeping is adequate to promote and safeguard the health, welfare and safety of the residents. EVIDENCE: A new person has been employed for the past two months in the manager’s post but has not yet applied to register with the Commission of Social Care Inspection (CSCI). The acting manager says he is mostly supernumery to staffing levels to enable him to bring documentation and policies and procedures up-to-date, organise the supervision of staff and monitor the service. Some relatives say that things have improved considerably since the acting manager started. The responsible individual has not undertaken the unannounced, monthly visits to the home. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 18 The business administrator showed that practices for handling residents’ personal finances are in order and robust. Where notifiable incidents or accidents occur, the Regulation 37 forms are now completed and sent to the CSCI. Accident forms have not been recorded on the appropriate forms. Staff have not had any supervision sessions and no staff meetings have taken place. They are frustrated because they feel they are not listened to. They want more training and time to do it without leaving the residents at risk. Fire awareness training has been completed by all staff. An environmental health report undertaken on 6th January 2005, made the following requirements: Training – care staff must undertake a basic food hygiene course. Insect killers – not efficient; must be replaced or repaired within three months. Fridge storage – the space was inadequate and the purchase of commercial fridges with extra capacity, deemed necessary. Action on these is monitored by the EHO. The call bell system is antiquated and inadequate: staff have to go to the office to determine which residents is seeking attention before being able to go to that resident. A large dog is often kept on the premises. This dog is boisterous and “sprightly” and, as expressed by relatives, could be a serious hazard and a danger to vulnerable residents. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 2 x x 2 2 2 STAFFING Standard No Score 27 2 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 2 x 3 2 x 3 Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 20 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 2 Regulation 5(3) Requirement Each resident must be supplied with a copy of the terms and conditions of his or her stay at home, including the fees payable and the room to be occupied. (Timescale of 31/03/05 not met.) Residents care plans must be in sufficient detail to enable staff to know how to meet their needs. Care plans must be kept under review. Care plans must show evidence of involvement of the resident or representative. Residents healthcare needs must be identified and kept under review. The advice of healthcare professionals must be sought. The responsible individual must re-assess the arrangements for the safe storage and administration of medications. Activities must be provided in sufficient quantity and variety to cater for the wishes and needs of the residents. Training must be provided for the protection and safety of vulnerable adults living in the Timescale for action 30/09/05 2. 7 15 30/09/05 3. 8 12(1) 30/09/05 4. 9 13(2) 30/09/05 5. 12 16(2) 30/09/05 6. 18 13(6) 30/09/05 Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 21 home. 7. 19 23(1,2) The registered person must ensure that the home meets with the wishes of residents in a comfortable and homely way. Bathroom facilities must meet the needs of residents and must be kept in a good state of repair. A maintenance plan must be produced which shows how and by when the re-decoration and refurbishment programme is to be completed. Radiators must be guarded or of a low surface temperature. Staff must be employed in sufficient numbers to keep the home clean and hygienic at all times. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health, welfare and safety of the residents. All staff employed in the home must receive training appropriate to the work they are to perform. The person appointed to manage the home must apply for registration with the Commission for the post. The responsible individual must ensure that the residents are cared for in a safe and appropriate manner by giving the acting manager sufficient supernumery time to complete documentation and policies and procedures. The responsible person must visit the home monthly, unannounced, and supply the Commission with a copy of the report written as required in this 30/09/05 8. 9. 21 24, 34 23(2) 23(2) 30/09/05 30/09/05 10. 11. 25 26 23(2) 13(3) 30/09/05 30/09/05 12. 27 18(1) 30/09/05 13. 14. 30 31 18(1) 9(2) 31/12/05 30/09/05 15. 31 18(1) Ongoing 16. 33 26 30/09/05 Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 22 regulation. 17. 36 18(2) The responsible person must ensure that persons working at the home are appropriately supervised. Accidents must be recorded on the appropriate forms, in accordance with the Data Protection Act 1998. 31/10/05 18. 38 17(2) 30/09/05 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. 2. Refer to Standard 36 Good Practice Recommendations It is recommended that staff supervisions should take place six times per year. Welbourn Manor C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unity House, The Point Weaver 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 C53 C04 S61236 Welbourn Manor V233552 160605 Stage 4.doc Version 1.30 Page 24 - 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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