Inspection on 20/07/05 for Welham House

This inspection was carried out on 20th July 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.

Other inspections for this house

Welham House 03/07/06

Welham House 01/09/05

Welham House 07/03/05

Welham House 28/06/04

Welham House 23/03/04

Welham House 24/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Welham House Hundleby Road Spilsby Lincs PE23 5LP Lead Inspector ken Hague Unannounced 20 July 2005 @ 8am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Welham House Address Hundleby Road Spilsby Lincs PE23 5LP 01790 752989 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) Boulevard Care N/A PC Care Home Only 14 Category(ies) of LD - Learning Disability - 14 registration, with number of places Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 7 March 2005 Brief Description of the Service: Welham house care home is owned by Bouvard Care Ltd. It is situated in the town of Spilsby. The 2-storey detached house has been adapted and extended to provide accommodation for 14 service users. The home caters for service users with a learning disability who require permanent or respite care. Bedroom accommodation is in single rooms. The home has a large through lounge and a separate dining area. Access to the first floor is obtained by a flight of stairs. The home has good access to the local community. A car park for visitors is provided at the rear of the care home. On road parking is also available. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place between 8am and 3pm. A second visit was made on the 1st of August to speak to service users at the of the day centre. The main method of inspection used is called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the premises was conducted, and care records were inspected. One member of staff, three service users, and the acting manager were interviewed. A discussion was held with the day centre manager at Orby day centre. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4, The home is not identifying the individual aspirations and needs of service users at the time the initial assessment is made. Her case is right about that and if I killed her The choices and wishes of the service users are not recorded. New service users are given the opportunity to visit the home prior to being admitted. EVIDENCE: The home has a statement of purpose which allows potential service users to identify the resources of the care home and make an informed decision whether their needs can be met by the resources and facilities offered by the home. In addition Bouvard Care have a ‘service user guide’, which is written in plain English and is given to new service users when they come to stay at the care home. There was however no evidence of the statement of purpose being shown to the last service user admitted to the home. The initial assessment records and the care plans failed to meet the National Minimum Standards. This was a case at the last inspection. The management of Boulavard care agreed that the care plans need extensive work on them to meet the National Minimum Standards. An action plan was agreed that an additional member of staff will be brought in to assist the acting manager with the care records. All care records will be reviewed to ensure that they meet the required standards within eight weeks. Staff stated all new service users are offer the opportunity of visit the home prior to making any decision to be admitted. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 9 Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 Care staff are aware of the wishing choice of service users but these were not recorded within individual care records. Staff assist service users to make decisions about their lifestyles. EVIDENCE: Care records contained many gaps in information which should have been attained at the initial assessment. The Review of care plans was not been carried out. Care records were difficult to follow, some information on care records was out of date. Discussions with staff provided evidence that care staff were aware of the needs wishes and choices of individual service users. It was agreed however that this was verbal information passed between staff rather than information recorded on care records. Service users views opinions and goals were not recorded within their care records. No evidence could be found from service user discussions or records that they were being included in the decision-making process. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,16 &17 A wide range of activities are available for service users to participate in, ensuring that they have an enjoyable and stimulating lifestyle. Catering arrangements reflect service users preferences and choices. EVIDENCE: Service users confirmed that activities are held at the care home. There at activities I shared with other Boulavard care homes. The day-care facilities are common to all Boulavard care homes and are offered at orby day centre. A visit was made to the day centre and discussions held with the day centre manager as well a service users. This centre offers activities based within the centre and social activities at leisure centres in the local area. Service users are given opportunities to improve computer skills take part in gardening activities and in arts and crafts. A service user who had shown little interest in activities was found now to be taking part enthusiastically in using computer I.T. equipment. It can be seen from care records that this is the first time this service user has had a any hobby or interest in his life. service users stated their likes and dislikes in relation to food. These details were recorded in their Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 12 individual files menu. Service rules confirmed that they were happy with menu being offered and the quality of food. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 All staff are following the Homes medication policy. This policy meets the National Minimum Standards. Medication is being provided to all service users in accordance with the instructions of their GP. The home completes records for the administration of medication. EVIDENCE: Staff stated that no service user in the home was self-medicating. The care plan records contain details of the medication for each service user. Medical history is recorded for service users. Staff confirmed that the company had provided formal training. Trained staff are allowed allow to administer medication in line with the companys medication policy. Service user stated that they were happy with their medication being provided to them by staff. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has robust procedures for handling complaints and allegations of adult abuse, and staff were clear on the action to take in the event of this occurring. Service users do feel confident in being able to raise complaints and concerns with the company. Service users feel safe living the care home but the failure to keep detailed assessments and care plans could in some circumstances place individual service users at risk. EVIDENCE: Boulavard care have a policy on identification and management of abuse in addition a copy of the Lincoln County Council adult abuse procedure is kept in the care home. Staff were able to describe the reporting procedures if theres any suspicion or concerns in relation to potential abuse. The members of staff interviewed as part of this inspection were able to describe the different types of abuse, which could occur in the care home. Staff confirmed that training in the identification and management of abuse has been provided. The service users stated that they considered the home is a safe environment in which to live. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25 EVIDENCE: A tour was made of care home. There was evidence of ongoing maintenance and repairs to the building. The bedrooms are individually personalised containing ornaments, hobby equipment of individual service users. The home was clean and tidy and free from any offensive odour. Service user stated their satisfaction with their individual bedrooms. Staff stated that Service users are actively encouraged to personalise their ownrooms. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35,36 Service users feel that competent, caring and considerate and well trained staff are meeting their needs. The manager ensures that staff are recruited safely by following the recruitment policy of the home which meets the National Minimum Standards. Supervision and appraisals are not been provided in accordance with the National Minimum Standards. EVIDENCE: A Service user stated that “staff are very helpful on always around would you need help”. Other service users stated their satisfaction with the staffing levels of the care home. Staff stated that they felt there was always sufficient staff on duty to meet the needs of service users. The atmosphere of the home at this inspection was much more relaxed than on past visits. There was evidence of good teamwork taking place between the members of staff on duty. A new member of staff interviewed stated that staff and particularly the staff member in charge was very supportive. The inspection of recruitment record for a member of staff provided evidence that the home was following its recruitment policy. This included the provision of inductions. Staff stated that the home is not providing formal supervision and appraisals as required by the National Minimum Standards. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 17 Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 All staff are following the health and safety policy of the Company. Repairs and maintenance to the building is being carried out. Any maintenance issue which relates to safety is dealt with as a matter of urgency. EVIDENCE: There were no health and safety issues identified at this inspection. A staff and service user stated in their opinion the home was a safe place in which to work or live. Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Welham House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 20 no 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&6 Regulation 14 Requirement The registered manager must ensure that all new service users are provided with an assessment. The registered person must ensure that service users have a written placement agreement which includes a service users plan. The registered person must provide appraisals and formal supervision to care staff. Timescale for action 28th october05 28th october 05 2. 5 15 3. 36 18 28th october 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. Refer to Standard Good Practice Recommendations Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Welham House C53 C04 S2564 Welham House V238779 20-7-05 Stage 4.doc Version 1.40 Page 22 - 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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