Inspection on 21/11/05 for Welbourn Manor

This inspection was carried out on 21st November 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 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 Manor 10/04/07

Welbourn Manor 11/04/06

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 Jean Cope Unannounced Inspection 14.00 21st November 2005 and 9 December 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Welbourn Manor DS0000061236.V272777.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.V272777.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), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (30) Welbourn Manor DS0000061236.V272777.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) (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. 2. Date of last inspection 16th June 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 does not provide any ensuite facilities. There are four communal bathrooms and eight toilets. Parking is available at the front of the building. Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a two day period. The first day of the inspection took place with the deputy manager, and the second day took place with the assistance of the acting manager. Both managers are new in post. One inspector toured the building, spoke with one member of staff the managerial staff and several residents living in the home. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care that they receive through the checking their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? The organisation has an ongoing programme of refurbishment and redecoration of the building. The communal areas, porch way and connecting corridors have had laminate floors laid, which staff said is working well. The corridors, upstairs and downstairs, and each bedroom have been fitted with new carpets. Individual rooms have been decorated, this continues as rooms are vacated. Since the last inspection the home has appointed a part time administrator. Many of the requirements left at the last inspection have been met. Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Welbourn Manor DS0000061236.V272777.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.V272777.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): 2, 3, 4 and 5 The acting manager will only admit new residents if she is sure that her staff and the home can meet their needs. EVIDENCE: Each resident is provided with a copy of terms and conditions on their admission to the home, which indicates what is provided within the contract, and what is not, which room the resident is to reside in and what fees are to be paid and by whom. The terms and conditions state that an eight week trial period is available for all residents. Prior to moving in the home, the acting manager visits prospective residents and undertakes an assessment to ensure that her staff and the home will be able to meet their needs. Information is gathered from families or friends, health and social care professionals. A visitor said that their friend’s needs were being met by staff in the home saying, ‘he is very happy and settled’. To ensure continuity of care in meeting Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 9 residents’ needs, a verbal handover with staff takes place on each shift change over. Welbourn Manor DS0000061236.V272777.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 and 10 The ordering, recording, storing and administration of medicines must be reviewed in line with the home’s medication policies and procedures to ensure the safety of residents. EVIDENCE: Each individual resident has a plan of care, which have mostly now been transferred, to a new system of recording care plans. Care plans record social and health care needs, which include falls assessments, nutritional assessments and dependency levels. Information from health and social care professionals was also available in residents’ files. As the home does not provide nursing care, community nurses provide support to residents requiring nursing care, they also provide specialist aids if necessary, such as pressure relieving mattresses and cushions. A sample of medication administration sheets were inspected which showed that some records had not been signed, therefore it was unclear as to whether medication had been given or not. The medication administration sheets were written out by hand by one person, but not checked by a second person to Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 11 ensure that they had been recorded accurately. A medicinal cream, which had been prescribed for an individual, no longer living in the home was found in a bathroom where it could be used communally. An inspection of the medication cupboard on the first day, showed that there was an overstocking of some medication. On the second day of the inspection, the acting manager said that she had inherited this situation and had spoken to the home’s pharmacist who had requested that the stock be used up and not returned, and that items should not be re-ordered until necessary. Only staff who have received medication training administer medication in the home. There are no lockable facilities in individual rooms if residents wished to self-medicate. Staff were seen knocking on residents’ doors prior to entering them. Welbourn Manor DS0000061236.V272777.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 and 14 Activities have improved in the home, but they are only available three days a week. Friends and relatives visiting residents are made to feel very welcome. EVIDENCE: An activities co-ordinator has been employed to work three days in the home. The co-coordinator has started to record the individual preferences of residents and offers activities which include, dominoes, card games, sing along and craft work sessions. She also spends time with individual residents, reading articles from the paper stories of their choice or just talking to them. When the weather is better, she and some of the residents have walks around the village and the home’s garden. A clothing party for residents has just been held. A PAT dog attends the home which residents enjoy. On the second day of the inspection the home had been decorated ready for Christmas and residents were looking forward to the nativity play to be performed by the local school children. A residents’ Christmas party and raffle had also been planned. Visitors were seen to be coming and going as they chose, and residents chose where they would like to spend their time. Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 13 One resident chooses to spend most of their time in their own room, preferring staff to enter only when necessary. As a result of this, staff clean the resident’s room whilst he is eating his lunch in the dining room. The home has regular church visitors and one resident attends her own church with assistance of church members. Welbourn Manor DS0000061236.V272777.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): 17 and 18 Staff have been trained in adult protection which should protect residents from abuse. EVIDENCE: Residents are offered postal votes at election time. All staff have received training on how to prevent and recognise adult abuse. Welbourn Manor DS0000061236.V272777.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, 25 and 26. Whilst many improvements to the home’s environment have been undertaken, bathrooms and toilets are in a poor state, shabby and unwelcoming for residents living there. EVIDENCE: Since the last inspection the communal sitting areas, dining room, porch and connecting corridor have been fitted with wooden laminate flooring. On the second day inspection, the upstairs and downstairs corridor and each individual resident’s rooms had been fitted with new carpets. Decoration is ongoing both in communal and individual’s rooms. Some radiators and pipe work, which were very hot to the touch, in the home remain uncovered. A risk assessment and appropriate action needs to be undertaken to ensure that they do not pose a hazard to residents living in the home. Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 16 Bathrooms and toilets in the home are in a very poor condition and need to be refurbished and decorated. They do not provide a homely environment for residents living in the home. Some commodes used in the home are old and rusty and do not provide a homely appearance in the home, but also cannot be properly cleaned to ensure the prevention of infection. The home was odour free throughout on both days of the inspection. A visitor commented, ‘the home is always warn and smells nice and clean’. Welbourn Manor DS0000061236.V272777.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 and 30 The home is staffed by a caring staff group who are committed to providing the residents with very good care. EVIDENCE: Three care assistants support the acting manager, who is not included in the shift. The home also employs housekeeping, kitchen staff, an administrator and maintenance person. Relatives commented, ‘staff are very caring and there’s a nice atmosphere here’. One member of staff said that within the last twelve months they had received training in first aid, moving and handling, medication administration, dementia care, infection control and adult protection. National Vocational Qualifications, (NVQ) have been recommenced after the home changed its training provider, however the home will not meet the target of having 50 of care staff qualified to NVQ level 2 by the end of 2005. Welbourn Manor DS0000061236.V272777.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 and 38 The acting manager has improved working relationships with staff and healthcare professionals to the benefit of the residents. EVIDENCE: The acting manager has been in post for ten weeks and has transferred from another home within the group. Staff reported a better atmosphere in the home. One staff member said, the manager ‘is lovely, we can talk to her and the relationship with the community nursing team has improved as a result’. The fire procedure is posted on the all in the event of a fire. The fire bells are tested on a weekly basis and recorded. Emergency lighting is checked monthly from different lighting points. Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 2 3 2 2 2 X 2 2 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X 2 Welbourn Manor DS0000061236.V272777.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13(2) Requirement The process of ordering medication must be reviewed to ensure there is no overstocking of medications. Staff working in the home must ensure that medication administration records are signed to evidence whether medication has been administered or not Handwritten medication records must be checked by a second person to ensure that correction amounts of medications are recorded to ensure the safety of residents. 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. An action plan must be submitted to Commission by 30/01/06 A risk assessment must be undertaken to ensure that hot radiators and pipework do not DS0000061236.V272777.R01.S.doc Timescale for action 30/01/06 2 OP9 13(2) 21/11/05 3 OP9 13(2) 30/01/06 4 OP21OP19 23(1,2) 30/01/06 5 OP21 23(2) 30/01/06 6 OP25 13(4) 30/01/06 Welbourn Manor Version 5.1 Page 21 7 OP30 18(1)(c)(i ) 8 9 OP26 OP31 23(2)(n) 9 10 11 OP31 OP36 10(2)(i) 18(2) pose as a hazard to residents. The registered person must submit an action plan on how staff will be trained to NVQ level 2 standard in order to meet the 50 target set by the National Minimum Standards. The provision of commodes must be audited and new commodes purchased where necessary The person appointed to manage the home must apply for registration with the Commission for the post. The acting manager needs to be enrolled on a Registered Managers Award NVQ level 4. The responsible person must ensure that persons working at the home are appropriately supervised. 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 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 OP22 Good Practice Recommendations When bedsides are being used, the acting manager needs to establish why they are being used and seek permission from the resident or family member or health professionals for consent. Welbourn Manor DS0000061236.V272777.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. 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