Inspection on 03/07/06 for Welham House

This inspection was carried out on 3rd July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 01/09/05

Welham House 20/07/05

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 Mr Ken Hague Key Unannounced Inspection 3rd August 2006 09:00 Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 Adults 18-65. 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. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welham House Address Hundleby Road Spilsby Lincs PE23 5LP 01790 752989 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) Boulevard Care Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 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 DS0000002564.V306465.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours. The commission received 9 residents’ feedback forms (“have your say documents”) from residents at the care home. This form asked residents 12 questions regarding services provided by the care home. All of these forms were analysed and their contributions are included in this report. Their comments and views are reflected within the inspection report. This information was analysed prior to making a site visit on the 3rd of August 2006. Feedback was given at the end of the inspection. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them and the staff, and where more appropriate observation of interaction between staff and residents. A sample of care records was inspected. The Inspector explained to a senior manager and a staff member in charge of the home on the day of the site visit the changes introduced in the inspection process since April 2006. What the service does well: What has improved since the last inspection? A staff training programme is in place. A large amount of work is being carried out on the environment of the home. Four bedrooms are being completely refurbished. Two additional bedrooms are being provided with increases Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 6 facilities to enable residents to work towards independence. A new staircase is being fitted and one bathroom fitted with a new bath, toilet and shower. 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. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 the following standard(s): 2 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. The home completes an assessments prior to admitting a resident to the care home ensuring that all their needs are identified and the care home has the resources to meet individual residents needs. EVIDENCE: This standard was met at the last inspection. Resident confirmed at the site visit that their individual care plan had been discussed with them before been used as a working document. The inspection of three individual files for residents being case tracked produced evidence that a full assessment including risk assessment was in place on each file. Evidence was found that the information from the assessment had been used to create a care plan and risk assessments where any risk had been identified. The assessments were written in language, which was easy to understand. All records were filed in the same order within individual files. The reader was therefore able to quickly understand the needs of the residents. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 6,7,& 8 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. Care plans contain comprehensive information, which identify the care needs and personal preferences of the residents. Risk assessments are of a good quality, providing management strategies that enable residents to be as independent as possible EVIDENCE: The care plans were found to be greatly improved at last the inspection in September 2005. At the site visit in August 2006 care plans of three residents being case tracked were found to be detailed, clearly written and easily explained the needs of the residents. The resident’s choice of lifestyle including the way they wished to spend their leisure time was recorded on their individual plan. Goals were included in care plans. Discussions were recorded in care records where staff had discussed the wishes of the residents and balance them against any identified risk. The “have your say” documents completed by nine residents stated that they are enabled to make choices in respect of their use of their personal time. A resident being case tracked had Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 10 been assessed and some risk areas identified. They needed to be supervised when within the community. The home enabled this resident to have maximum choice in terms of lifestyle while ensuring any identified risk was being managed therefore preventing or reducing any difficulties and problems. A second resident wished to move into the community to live with a partner. The care plan indicated how this goal may be achieved. A discussion was observed between the resident and a senior member of management who listened carefully to the residents opinions. They were supportive to the resident and answered all questions in a sensitive manner. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to this service. Activities are organised for the residents staying in the home, which include community activities and local events. Residents are encouraged to make links into the local community. Family and friends are encouraged ,to maintain contact with residents while they are staying at the care home. staff respect the rights and dignity of residents. The home’s menu, meets the needs of residents. Choice of food is of offered, individual dietary needs are met. EVIDENCE: The Pre- inspection questionnaire sets out the range of activities offered to residents. The individual files of residents contain their choices of individual activities. The have your say document confirmed the activities are provided and choices are offered to residents in how they spend their social and leisure time. Residents stated that they were happy with the activities and community activities organised by the care home. A senior member of staff stated residents regularly go out into the community evidence to support this statement was found in discussions with residents, observation and photographs taken at social events. There was evidence found on the care records of a residents being case tracked that the staff were Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 12 helping her working towards living in the community with a resident of another care home. The pre-inspection questionnaire contained a menu for the home which demonstrated that choice is offered to residents. The “have your say” documents provided additional evidence that residents are happy with the menu and that their individual dietary needs were being met. Residents spoken to during the site visit stated that they were happy with the home’s menu. A Individual resident said “I often make small meals and help in the kitchen.” Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home provides personal support in the manner preferred by each individual resident. Residents physical and emotional health needs are being met. Staff have been trained to ensure they can administer and manage the storage of medication for residents. EVIDENCE: A senior member of the management team stated that all “residents care plans include their identified health, personal and social care needs. Chiropody, dental checks and eye care are arranged for all residents, Staff assist residents to keep hospital and doctor appointments.” The case tracking process and inspection of resident’s individual file confirmed this statement to be correct. The nine “have your say” documents completed by residents provided evidence that residents feel they received the care and support they need and that their health care needs are being met. Staff interviewed stated that they had received training in the administration and storage of medication. No residents were self-medicating. The Inspector observed a member of staff and Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 14 administer medication to four residents. He followed the medication policy of the care home, which meets the National Minimum Standards. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 22&23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home listens to resident’s views and wishes and acts on them. There are procedures in place to protect residents from any possible abuse. Staff have received appropriate training to protect residents from being harmed. EVIDENCE: The home’s complaints policy meets the National Minimum Standards it is known to residents. The evidence for the statement comes from comments in the have your say documents completed by residents prior to the site visit. The home was following the Lincolnshire county council vulnerable abuse procedure in respect of a concern raised in June 2006. The company has therefore demonstrated that it is has followed its own abuse procedure and liaison with agencies as required in the Lincolnshire county Council vulnerable abuse procedure. Care records and training records confirm that all staff have been training in the identification of abuse and understand what action to take in the event that they have any suspicion of abuse taking place. Residents stated at the site visit that they feel protected and safe living in the care home. The company has reviewed its financial procedure to ensure the protection of residents finances during 2006. A senior manager stated during the site visit that the company are satisfied all appropriate steps have been taken to protect resident’s finances. Additional monitoring visits by senior management in respect of these records are being introduced across the company. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 24 & 30 Quality in this outcome area is Excellent. This judgement has been made using the available evidence including a visit to this service. Residents live in a well maintained clean environment. Work carried out by the company since the last site visit means that they have exceeded the National Minimum Standards in this area. EVIDENCE: Major changes have been made to the environment of the care home. Four bedrooms have been completely refurbished with repairs to floors new doors and door frames with modern pine fittings. One bathroom has been completely refurbished. Additional facilities have been added to a further two bedrooms to allow the residents to work towards independence. One main staircase is to be replaced in the next month. One resident requested the Inspector to look at his bedroom. He said that he was very satisfied with his room. On the day of the site visit the home was clean and smelt fresh. There were comments in the “have your say document” which provided additional evidence that in the residents opinion the home is always clean. One resident stated, “this home is spotless”. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 17 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 32, 34 and 35 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 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Residents live in a care home, which is safe and free of any health and safety hazard. Staff listen, and take into account the wishes of residents when planning the development of the care home. The Home’s management offers positive leadership to all staff EVIDENCE: Staff and residents stated that they find the management team very supportive. Recruitment records provided evidence that all new staff have been recruited in accordance with the National Minimum Standards using the company’s recruitment procedure. Discussions with staff, residents and the inspection of staff rotas and training records provided evidence, that there are always sufficient staff on duty to be able to meet the needs of residents who fall within the registration category of the care home. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has an experienced acting manager in post, who ensures that the National Minimum Standards are met and is very supportive to all staff The residents feel that the home is run in their best interest. Financial records and procedures are in place to safeguard the financial interest of resident. All staff are being recruited appropriately and provided with induction training. EVIDENCE: The have been three acting managers in his home in the last 18 months which could have produced some instability. Detailed discussions were held with a senior manager, the administrator and a senior carer on the day of the site visit. Evidence was produced and substantiated during discussions with staff members and residents that a management structure is in place, which includes defined roles of management. The home caries out regular quality assurance surveys. The “have your say documents” provided more evidence that staff listen to and act on the wishes of the residents. Residents confirmed Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 19 that the home holds residents meetings. One resident stated “I feel very happy living in this home”. There were no negative comments passed at all by any resident during the site visit to this care home. Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 x 2 4 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Welham House DS0000002564.V306465.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Welham House DS0000002564.V306465.R01.S.doc Version 5.2 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!