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Inspection on 05/10/05 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 5th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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?

A new stair lift has been installed and redecoration of the entrance hall and staircase has been carried out. New carpets have also been laid in these areas. Improvements have been made to the first floor communal toilet to offer more space to residents and two ensuite toilets are in the process of being redecorated with new floors being laid.

What the care home could do better:

Ensure that residents are safe when being transported in wheelchairs. If more thorough needs assessments were carried out staff would get a better picture of the care needs of the resident and be able to provide the appropriate level of care.Confirm in writing when verbal references have been sought; this would demonstrate that the manager has carried out the necessary checks when employing staff. Ensure that the Commission for Social Care Inspection are notified of death, illness and other events as listed in Regulation 37 of The Care Homes Regulations 2001.

CARE HOMES FOR OLDER PEOPLE Welford Court Residential Home 458 Welford Road Knighton Leicester Leicestershire LE2 6EL Lead Inspector Mrs Diane Butler Unannounced Inspection 5th October 2005 10:00 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 Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Welford Court Residential Home Address 458 Welford Road Knighton Leicester Leicestershire LE2 6EL 0116 270 3482 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) Welford Court Limited Mr Christopher Kemp Care Home 14 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (14), Sensory Impairment over 65 years of age (2) Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers. No person 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. No person falling within category SI(E) may be admitted to the home when 2 persons in total of this category are already accommodated within the home. 12th may 2005 2. Date of last inspection 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. 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 Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 5th October 2005 and commenced at 10.00am. 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 staff and observation of care practices. The Commission for Social Care Inspection is inspecting Welford Court for the eighth 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: Ensure that residents are safe when being transported in wheelchairs. If more thorough needs assessments were carried out staff would get a better picture of the care needs of the resident and be able to provide the appropriate level of care. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 6 Confirm in writing when verbal references have been sought; this would demonstrate that the manager has carried out the necessary checks when employing staff. Ensure that the Commission for Social Care Inspection are notified of death, illness and other events as listed in Regulation 37 of The Care Homes Regulations 2001. 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 Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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): 2,3,5 Standard 6 was not applicable at the time of the inspection. Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of the home. More thorough needs assessments would ensure that the residents care needs were fully identified. EVIDENCE: • Three resident files were inspected. All were found to include either an individual placement agreement or a private contract. It was noted that the contract for the resident who was privately funded had not been completed or signed by either the service user/representative or the registered manager. All three files included a needs assessment document. It was noted that these documents were quite vague in content and did not give a clear picture of the residents needs at the time of moving into the home. The manager explained that whilst not all the information was recorded on the forms he would know during the assessment visit whether or not their needs could be met. DS0000006447.V256018.R01.S.doc Version 5.0 Page 9 • Welford Court Residential Home • 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. One resident spoken with stated: “My son visited the home before I moved in to make sure it would be the right place for me”. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 Residents are looked after well in respect of their health and personal care needs and personal support is offered in such a way as to protect the resident’s privacy, dignity and independence. EVIDENCE: • Three care plans were looked at during the inspection. Evidence was seen in one of the care plans of the resident’s relatives having involvement in the development of the plan. The care plan is a one page checklist which enables the carer to have an over view of the needs of the residents. Any specific needs identified from this sheet would be written up in more detail on an additional information sheet. The more care a resident requires, the more additional information sheets would be included in the care plan. It was questioned whether this was sufficient information to enable the carers to carry out the care required of them, however through speaking with the residents and the staff it was evident that current needs were being met. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 11 • • • • Reviews of the care plans are carried out on a monthly basis and daily records are kept for each resident. The Procedures for the administration of medication were in order with all paperwork completed appropriately. 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. Comments made by residents during the inspection included: “The staff are very good” “I am very happy here” “I think its great, its very much like home” “They treat me very well”. • Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 relaxed homely life style within the home enables residents to make choices on a daily basis. EVIDENCE: • Family and friends are encouraged to visit the residents. One resident spoken with stated: “I think its super, my relatives can visit at any time”. • 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. The meals in the home are good offering choice and variety. All residents spoken with stated that they enjoyed the food. One resident stated: “You can’t fault the food at all” • Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 the following 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. EVIDENCE: • There is a complaints procedure in place and details of this are included in the Statement of Purpose document. The registered manager explained that no complaints had been received since the last inspection in May this year. This statement was supported on checking the complaints book. One resident spoken with stated, “If I had any worries I would talk to Chris [manager], he would look after me. Chris is great we look after each other”. Staff spoken with during the inspection were aware of what to do should they suspect any act of abuse and the registered manager is aware of the procedure to follow with regard to adult protection. • • Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 the following standard(s): 19, 21,25,26 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. A new stair lift has been installed and new carpets have been laid in the entrance hall and staircase. The redecoration of the hallway and stairs has taken place and two ensuites are currently being decorated and new floors are to be laid. All areas of the home seen on this occasion were clean and fresh. • • Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 15 Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 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): 27,29,30 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 currently there were enough staff on duty to care properly for the residents. Two staff files were checked. One included all the necessary information, including two references, proof of identity and a Criminal Record Bureau check (CRB), the second had a CRB and proof of identity but no references. The manager stated that he had received verbal references for the carer, but had not recorded these. 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. • • Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 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): 32,34,35,38 The home is managed efficiently and appropriate policies and procedures are in place to ensure the safety of the residents. EVIDENCE: • It was evident during the inspection that the residents benefited from the ethos, leadership and management that the registered manager and care manager provides. All staff and residents spoken with during the inspection stated that he manager was approachable, supportive and always available. The registered manager stated that the home did not keep money on resident’s behalf. The inspector was informed that any purchases necessary would be made then the money would be collected from the resident/representative afterwards. DS0000006447.V256018.R01.S.doc Version 5.0 Page 18 • • Welford Court Residential Home • • • Fire records were in order with the last fire drill being carried out on 11th August 2005. The accident book was seen and was found to correspond with the resident’s daily records. During the inspection a resident was seen being transported in a wheelchair with out the use of footplates. The registered manager stated that he knew no reason for this and would look into it. An immediate requirement sheet was left. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 2 2 X 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 X 18 3 3 X 3 X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X X 2 Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 OP38 Regulation 13 Requirement The registered provider must ensure the safety of service users whilst transporting in a wheelchair. The registered provider must demonstrate that all required checks have been completed before employing new staff. The registered person must ensure that the CSCI is notified of events listed in Regulation 37 of The Care Homes Regulations 2001 Timescale for action 10/10/05 2 OP29 17 10/10/05 3 OP37 37 10/10/05 Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 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 2 Refer to Standard OP2 OP3 Good Practice Recommendations The registered person should ensure that the contract kept on the service users file is signed by both the service user or their representative and a representative of the home. The registered provider should complete a more thorough needs assessment before a resident moves into the home to ensure all care needs are identified. Welford Court Residential Home DS0000006447.V256018.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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. 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