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Inspection on 12/05/05 for Welford Court Residential Home

Also see our care home review for Welford Court Residential Home for more information

This inspection was carried out on 12th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a happy and relaxed atmosphere offering support to residents in a dignified manner. The staff have a good understanding of the residents in their care. This is evident from the positive relationships, which have been formed between the staff and the residents. Residents have a varied life at the home with regular activities offered. Staff have a good understanding of adult protection and are aware of what to do should they suspect anything untoward.

What has improved since the last inspection?

Improvements are currently being made to the first floor communal toilet to offer more space to residents.

What the care home could do better:

If care plans and risk assessments were completed on admission care needs and any possible risks could be identified allowing staff to provide the appropriate level of care. If all identified care needs were included in the residents care plans staff would know exactly what support they should be offering the residents. If equipment necessary to support a resident who has a catheter was available, staff would be able to provide care in line with the homes infection control policy.

CARE HOMES FOR OLDER PEOPLE Welford Court 455 Welford Road Knighton Leicester LE2 6EL Lead Inspector Diane Butler Unannounced 12 May 2005 at 9.30am 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. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Welford Court Address 455 Welford Road Knighton Leicester LE2 6EL 0116 270 3482 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) Welford Court Limited Mr Christopher Kemp Care Home 14 Category(ies) of OP Old Age - 14 registration, with number MD(E) Mental Disorder over 65 - 5 of places SI(E) Sensory Impairment over 65 - 2 DE(E) Dementia over 65 - 5 Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No persons falling within SI (E) may be admitted to the home when 2 persons in total of this category are already accomodated within the home. 2. No persons falling within categories MD (E) or DE (E) may be admitted to the home when 5 persons in total of these categories/combined categories are already accommodated within the home. Date of last inspection 23rd November 2005 Brief Description of the Service: Welford Court is a detached property on the Welford Road within the boundaries of Leicester. The home is an adapted property, and can admit up to fourteen service users within the categories of OP, Older Persons, DE(E), Dementia, SI(E), Sensory Impairment and MD(E), Mental Disorder. The home is on the major bus route into the city of Leicester, and is situated a short distance from the local shops. The bedrooms are on both floors of the home and a stair lift serves the upper floor of the building. There are two lounges and a dining room. There is a large and pleasant secure garden and small conservatory to the rear of the building. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five and three quarter hours and commenced at 9.30am on 12th May 2005. The main method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The Commission for Social Care Inspection is inspecting Welford Court for the seventh time and is in its third year of inspections being inspected against the Care Standards Act 2000. The registered manager was most helpful during the inspection process. What the service does well: What has improved since the last inspection? What they could do better: If care plans and risk assessments were completed on admission care needs and any possible risks could be identified allowing staff to provide the appropriate level of care. If all identified care needs were included in the residents care plans staff would know exactly what support they should be offering the residents. If equipment necessary to support a resident who has a catheter was available, staff would be able to provide care in line with the homes infection control policy. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 6 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. Welford Court C51 S6447 Welford Court V225964 120505.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 Welford Court C51 S6447 Welford Court V225964 120505.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, 4, Standard 6 was not applicable at the time of the inspection. Prospective residents are given detailed information about the home and its services enabling them to make an informed decision about admission to the home. The admission process in place ensures that the residents identified care needs are met. EVIDENCE: • A Statement of Purpose and a Service User Guide are available. The manager explained that these documents, which include information about the facilities in the home and the services that can be provided, are explained to all new residents. Prospective residents and their relatives are invited to look around the home to enable them to see how their care needs would be met by the staff working at the home. • Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 9 • Three resident files were looked at during the inspection. These were found to include an initial assessment carried out by the manager and the appropriate contracts. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 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 standard(s) 7,8,9,10 Residents are currently looked after well in respect of their health and personal care however lack of care plans or risk assessments could potentially put resident’s health and welfare at risk. EVIDENCE: • Three resident files were looked at during the inspection. It was noted that there was no care plan or risk assessment in place for the newest resident, even though their initial needs assessment identified the resident was at risk of falls and diagnosed as having dementia. Evidence was seen of GP’s and community nurses visiting, with the Community Nurse visiting on the day of the inspection. During the inspection one of the residents case tracked was seen being transported in a wheelchair with out the use of footplates. The inspector was informed this was because the resident had sore heals. This was not included in the residents care plan and no risk assessment had been completed. • • Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 11 • • • • Medication records were in order. On inspection of the medication blister packs it was noted that a system of secondary dispensing was in place. All staff spoken with during the inspection were aware of the individual care needs of the residents case tracked. It was noted that two residents with catheters did not have catheter bag stands for use at night. Discussion with residents and staff and observations during the inspection showed that the staff had a good awareness of how to ensure a resident’s privacy and dignity are maintained. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 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 standard(s) 12,13,14,15 Regular activities and a variety of meals enable residents to make preferred choices on a daily basis. EVIDENCE: • Choices are offered to residents on a daily basis including what to wear, when to retire to bed, what and where to eat lunch and whether to join in activities. An activities leader is employed for three days per week and a variety of activities are offered. The meals in the home are good offering choice and variety. All residents spoken with stated that they enjoyed the food. Comments received from the residents included: “I’m a pudding person, I always eat my puddings” “They give me far too much” “The food is very good” • • Visitors are encouraged, one resident explained, “Visitors are treated as we are, and they always get a courtesy cup of tea”. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 13 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 Arrangements for the receiving and responding to complaints are satisfactory and residents are confident that their concerns will be listened to, taken seriously and acted upon. Staff awareness of possible abuse situations ensures protection of the residents in their care. EVIDENCE: • There is a complaints procedure in place and details of this are included in the Statement of Purpose document. The manager explained that no complaints had been received since the last inspection in November last year. This statement was supported on checking the complaints book. A resident spoken with stated, “I never worry”. Staff spoken with during the inspection were aware of what to do should they suspect any act of abuse and the registered manager was aware of the procedure to follow with regard to adult protection. • Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 14 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) 19,20,21,22,23,24,25,26 The standard of the environment within this home is good providing residents with a comfortable and homely place to live. EVIDENCE: • The home is safe and well maintained. Decoration in the home is of good standard and furnishings in the communal areas are domestic in character and in good condition. Personal possessions were evident in the rooms that were checked and specialist equipment including a pressure mattress and cushions were in place. The toilet on the first floor is in the process of being enlarged and redecorated. C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 15 • • Welford Court • All areas of the home seen on this occasion were clean and fresh. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 16 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) 27,28,29 Staff are currently employed in sufficient numbers to meet the needs of the residents. Appropriate procedures for the recruitment of staff are in place to ensure residents are not put at risk. EVIDENCE: • There were sufficient numbers of staff on duty on the day of the inspection to meet the current needs of the residents. Staff spoken with agreed that bar any sickness, there were enough staff on duty to care properly for the residents. All the staff on duty on the day of the inspection were well aware of the care needs of the residents that were case tracked. The file belonging to the newest staff member was checked. It was noted that a Criminal Record Bureau check was in place though references had not yet been received. The manager stated that the member of staff would not be delivering personal care until the references were in place. • • Welford Court C51 S6447 Welford Court V225964 120505.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) 31,32,37,38 The home is managed efficiently and appropriate policies and procedures are in place to ensure the safety of the residents. EVIDENCE: • The registered manager is currently completing a National Vocational Qualification level four in care and management, and all staff and residents spoken with stated that he was approachable and supportive. Staff meetings are held on a regular basis, the last of which was held on 27th April 2005. Fire records were in order with the last fire drill being carried out on 5th April 2005. Testing of all the portable appliances in the home was being carried out on the day of the inspection. • • Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 18 • During the inspection protective clothing was used to prevent the spread of infection. Welford Court C51 S6447 Welford Court V225964 120505.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 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x 3 3 Welford Court C51 S6447 Welford Court V225964 120505.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 7 Regulation 15 Requirement The Registered Person must: 1: ensure that care plans are in place for all service users. 2: ensure all identified care needs are included in the care plan. The Registered Person must ensure that the necessary risk assessments are completed to ensure the safety of the resident and act on the findings. The Registered Person must ensure the neccesary equipment is in place with regard to catheter care. The Registered Person must contact the contracting pharmacist with regard to secondary dispensing of medication and act on advice given. Timescale for action With immediate iffect on reciept of this report. 2. 8 13 3. 8 13 4. 9 13 With immediate effect on reciept of this report. With immediate effect on reciept of this report. With immediate effect on reciept of this report. Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 21 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 None Good Practice Recommendations Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 Page 22 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Welford Court C51 S6447 Welford Court V225964 120505.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!