Inspection on 20/06/06 for Well Springs Nursing Home

This inspection was carried out on 20th June 2006.

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.

Other inspections for this house

Well Springs Nursing Home 26/06/07

Well Springs Nursing Home 21/02/06

Well Springs Nursing Home 14/06/05

Well Springs Nursing Home 08/02/05

Well Springs Nursing Home 17/08/04

Well Springs Nursing Home 03/03/04

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Snydale Care Home

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Well Springs Nursing Home 122 Leylands Lane Heaton Bradford West Yorkshire BD9 5QU Lead Inspector Mary Bentley Unannounced Inspection 20th June 2006 09:30 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 Well Springs Nursing Home DS0000042143.V297901.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 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. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Well Springs Nursing Home Address 122 Leylands Lane Heaton Bradford West Yorkshire BD9 5QU 01274 488855 01274 544801 sueseal@btconnect.com 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) Rossefield Nursing Homes Limited Mrs Jean Ward Care Home 52 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (52), of places Physical disability (10), Terminally ill over 65 years of age (3) Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Well Springs provides nursing care for 52 people, male and female, predominately over the age of 65 years. Accommodation is provided in both single and shared rooms on the ground and first floors. There is a large lounge and two conservatories on the ground floor. The home is situated in the Heaton area of Bradford approximately 2 miles from the city centre. Local shops and amenities are situated close to the home. The detached property is set in extensive private gardens with parking space provided within the grounds. The weekly fees range from £318.00 to £658.00. Hairdressing, chiropody, newspapers, taxis and personal requests are not included in the fees. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was in February 2006 and identified a number of concerns. These included care planning, the management of pressure area care and wound care, the management of nutrition and falls and staffing levels in the home. Following that visit a letter was sent to the providers informing them of our serious concerns. A further unannounced inspection was done in May 2006. That inspection showed that although some work had been done on the care records they did not meet the required standards and that the concerns about staffing levels had not been addressed. Following that visit the providers was asked to put forward their staffing proposals for the home and sample care plans were sent to the CSCI for comment. Since the last inspection there has been one referral to the Local Authority Adult Protection Unit and one of the outcomes was that the home was given guidance on care planning by nursing staff from the local Primary Care Trust. The purpose of this inspection was to inspect all the key standards, (the key standards are identified in the main body of the report), to assess how the needs of people living in the home are being met. The methods used in this inspection included looking at care records, talking to residents, observing care practices in the home, talking to relatives, talking to staff and management, looking at some parts of the home and looking at other paperwork including staff and maintenance records. The home completed a pre-inspection questionnaire and the information provided was used as part of the inspection. The inspection visit was unannounced; it was carried out on 20 and 21 June 2006. On 20/06/06 two inspectors were in the home from 9.30am until 5.00pm and on 21/06/06 the inspectors spent approximately two and a half hours in the home giving feedback. Feedback was given to the deputy manager and general manager. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 6 Comment cards were sent to a small number of residents before the inspection and comment cards for residents and relatives were left at the home. These provide people with an opportunity to share their views of the service with the CSCI. Information obtained in this way is discussed with the home without identifying who has provided it. A number of comment cards from residents and relatives were returned to the CSCI, overall people said they were satisfied with the services provided, more specific comments have been incorporated into the relevant sections this report. Comment cards were also sent to a number of GP practices, three were returned and indicated overall satisfaction with the home; one referred to some concerns about the management of pressure sores. What the service does well: What has improved since the last inspection? The management team have taken on board the concerns about the care records. Although the new system for care planning has not yet been implemented they said they are now confident that they know what is required to bring the records up to the required standard. There has been an improvement in how the nutritional needs of residents are dealt with and the home has appointed link nurses to be responsible for continence and tissue viability. The number of staff on duty at night has been increased. The home has issued questionnaires to residents and relatives asking for their views of the service. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 7 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. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 8 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 Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 9 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): 3 & 5. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The needs of prospective residents are assessed before they are admitted to the home. The home encourages prospective residents and/or their representatives to visit before making a decision about admission. EVIDENCE: The format of the pre-admission assessment form has been changed and it is now possible to record detailed information about needs of prospective residents. In one of the care records looked at the new pre-admission assessment form had been used, the information was brief but the home had obtained copies of assessments carried out by other professionals and all the information together provided a detailed picture of the resident’s needs. The pre-admission assessment completed by the home had not been signed or dated. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 10 Two relatives said they had been able to visit the home before making a decision about admission. Both said they had been made welcome, shown around and given plenty of information. One said she was particularly pleased that she had not needed an appointment to visit. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Residents and relatives were, for the most part, satisfied that care needs were being met and that privacy and dignity were respected. However the absence of detailed care plans means it is difficult to make sure that appropriate care is delivered consistently. This creates the opportunity for care needs to be overlooked. Some of the practices in relation to the management of medicines create the opportunity for residents to be put at risk. EVIDENCE: At the inspection in February 2006 a number of concerns were identified with regard to the care records. To summarise the records did not set out in detail how the personal, health, and social care needs of residents would be met and there was no evidence that residents or their representatives were involved in the care planning process. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 12 Following that inspection the home received support from nursing staff employed by the local PCT (Primary Care Trust) to help them develop their care planning to the required standard. A number of care plans were looked at during the May 2006 inspection and while some efforts had been made to improve the records there were still a significant number of shortfalls. The home was informed of the areas that needed to improve. Following that inspection the home sent two samples of care plans to the CSCI and was given detailed feedback. At the time of this inspection the deputy manager said that they had not yet implemented the new care plans, because they had been waiting for feedback from the CSCI. However she said she was now confident that she understood what was required and would go ahead with making sure that all the care plans were updated. The home has purchased a new system for organising care records that will make sure that all the records relating to each individual resident are kept together. The home currently uses separate books, such as bath books and bowel books, to record information about individual residents. This makes it difficult to get a clear picture of how peoples’ needs are being met, does not encourage a person centred approach to care and makes it more difficult for residents to have access to their care records. We looked at four care plans during this visit and further feedback was given to the deputy manager. Concerns about the standard of record keeping around the management of pressure areas and wounds were raised at previous inspections and further concerns were identified during this visit. In one of the care files there was an entry in the daily records relating to skin discolouration in the sacral area but there was no care plan to follow this up. In another file there was a dressing plan for a wound but there was no evidence of wound grading. There was an entry saying the wound was getting smaller but it was not clear how staff could know this, as there was no evidence that the wound had been measured. There were a number of examples of problems identified in the daily records but not followed up in care plans, for example in one of the care plans there were entries dating back three weeks referring to the fact that the resident had a swollen and painful hand. The records also showed that the resident was being given regular analgesia although none was prescribed. In another file a risk assessment had been done because the resident smoked but there was no evidence that the resident had been involved despite the fact that that she was capable of taking part in this process. No concerns were identified with regard to nutrition; the files seen showed that residents were gaining weight. The home has appointed continence link nurses and a tissue viability link nurse, they will work with specialist nurses from the local PCT to make sure that practices in the home are in line with current best practice. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 13 The moving and handling risk assessments do not contain enough detailed information. A trained moving and handling co-ordinator had not carried out the moving and handling assessments. Generally residents and relatives were satisfied that their health and personal care needs were being met and felt the staff were kind. Residents are helped to get access to equipment such as wheelchairs. For the most part privacy and dignity are respected although on some occasions staff were observed entering rooms without knocking on doors. The home has the required policies and procedures in place for the safe management of medicines. A new larger fridge for storing medicines was being installed at the time of the inspection. A random selection of controlled medicines was checked and was correct. None of the residents in the home were dispensing their own medication. Some concerns were identified with regard to the giving of un-prescribed analgesia and the practice of secondary dispensing of medication for one resident who goes out regularly. Creams prescribed for individual residents had been left in the communal bathrooms. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home offers a reasonable range of in-house social activities however more needs to be done to make sure that activities programme takes account of the needs and preferences of individual residents. Residents are supported in keeping in touch with their families and friends. Some progress has been made towards creating a more flexible environment where residents are encouraged to exercise choice and control over their lives. The home provides wholesome and appetising meals and the menus are varied; residents said they enjoyed the food. EVIDENCE: The home offers a programme of activities, which includes things such as crafts, dominoes, bingo and coffee mornings. Some personal information is recorded for residents but this is not used to develop individual social care plans. The recent survey carried out by the home showed that 46 of relatives and 66 of residents who responded said they were satisfied with the variety of activities offered. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 15 There is some degree of flexibility in daily routines although residents preferred times for going to bed and getting up are not recorded. The notes of the last residents committee meeting showed that the home was planning to consult people about this. There are no restrictions on visiting and some relatives visit every day. One visitor said she regularly has her lunch at the home, on the day of the inspection she was sitting outside having lunch with her relative. However although this is clearly an important aspect of that persons care there was no reference to it in the care records. There were some attempts to meet the spiritual needs of residents, although this was not consistent in the care records looked at. For example one file showed that the resident was a devout Christian but there was no information on how this need was being dealt with. Another resident goes out regularly to church and some religious services are held in the home. Residents generally were satisfied with the food; one said, “It is good and varied”. Residents are consulted about their preferences; we heard a member of staff trying to encourage a resident, who had refused lunch, to eat their evening meal by offering “a really nice bacon sandwich”. The homes survey showed that 83 of residents and 84 of relatives who responded were satisfied with the food. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home has a complaints procedure and in general complaints are dealt with appropriately. The home has the required policies and procedures to make sure that residents are protected. However in order for these procedures to be effective staff that are left in charge of the home must be familiar with them. EVIDENCE: The survey carried out by the home showed that 74 of residents and 96 of relatives who responded felt able to raise concerns or make suggestions. Comment cards returned to the CSCI from residents and relatives also showed that most people were aware of the home’s complaint procedures. Relatives spoken to during the visit felt confident that could raise any concerns they might have. The home has a system for recording complaints, this was discussed during feedback, and suggestions were made as to how it could be improved. A copy of the local authority Adult Protection procedures is available in the home. Training has been booked for senior staff on Adult Protection and is scheduled to take place later this year. It is acknowledged that the delay is due to the very high demand for the training run by Bradford Social Services. However, in the interim the management team must make sure that sure that Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 17 staff, particularly those left in charge of the home, are aware of what actions to take in the event of suspicions or allegations of abuse. The nurse in charge of the evening shift on the first day of the inspection did not know how to deal with a report of suspected or alleged abuse. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home is clean, safe, and well maintained. The communal rooms and bedrooms are comfortable and residents have access to safe and pleasant gardens. The call bells in the communal rooms are not easily accessible, which means that people using these rooms sometimes find it difficult to call for assistance when they need it. The temporary reduction in the number of available bathrooms, due to improvement works, will inevitably cause some disruption to residents preferred bathing routines. EVIDENCE: When the home was visited in May 2006 repairs were being carried out on the roof, these are now completed and the damaged areas are being redecorated. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 19 The carpet in the area near the nurses’ station on the ground floor will be replaced when the decorators have finished. The main lounge is showing signs of wear and tear. The general manager said it was scheduled for refurbishment but the plans had been delayed because priority had been given to the roof repairs and fire safety work. The provider confirmed that work is being done to meet the recommendations of the Fire Safety report. The gardens are lovely, they are well kept and accessible and enjoyed by residents and visitors. The bedrooms seen were suitably equipped to meet residents’ needs, they were nicely decorated, and people had their personal belongings around them. The home has two mobile hoists; the deputy manager said the home was planning to purchase another hoist. The call bells in the main lounge and conservatory do not have leads attached making it difficult for residents to call for assistance. The notes of the residents meeting identified this as a problem. It was noted that residents had asked for a bell so that they could attract the attention of staff. The notes suggested this was particularly a problem in the evening. There were only 2 communal baths/showers in use at the time of the inspection because of renovation work. It was not clear what, if any, consultation there had been with residents about this and how it would affect their bathing routines. When the work is completed the home will have six communal baths/showers. Hot water temperatures in washbasins are checked regularly and recorded. The hot water temperatures for baths/showers have not been recorded; the deputy manager said staff check the temperatures before residents use the bath/shower. The laundry is well equipped but the position of the machines makes it difficult to get behind the machines for cleaning. A build up of fluff and/or dust in this area could be a fire hazard. Staff working in the laundry understood the procedures to follow to reduce the risk of cross infection. There were examples of good practice in the way the home delivers the laundry service. Laundry staff check residents rooms regularly to make sure that wardrobes and drawers are tidy and that residents have their own clothes. The home employs someone solely for the purpose of hand washing delicate items of residents’ personal clothing. The home was clean and two regular visitors said it was always clean and there were never any unpleasant odours. There was a slight odour in one bedroom, the deputy manager was aware of this. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 20 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. There are not always enough staff on duty to make sure that residents needs are met in a timely manner. Residents are protected by the homes’ recruitment procedures and staff are supported in developing their skills and knowledge. EVIDENCE: At the inspection in February 2006 concerns were raised about the staffing levels in the home particularly on the evening and night shifts. The main concerns were that, for 52 residents, the home was working with one nurse on duty between the hours of 4.00pm and 7.00am and a total of four staff on night duty. At that time the manager said that the number of nursing staff on the morning shift had been increased from two to three. During the follow up visit in May 2006 we looked at the duty rosters covering a four-week period. They showed that the home was not consistently providing three nurses on the morning shift, there were at least two days every week when there were only two nurses on duty. At that time the number of staff on night duty remained unchanged with a total of four staff on duty. Following that visit the home increased the number of staff on night duty, there are now a total of five, one nurse and four care assistants. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 21 At the end of May 2006, in response to a request from the CSCI, the owners set out their staffing proposals for the minimum number of staff to be on duty at any time. In terms of nursing staff the owners said there would be a minimum of three on the morning shift, (until 2.00pm) and a minimum of two on the afternoon shift, (until 5.00pm). There would then be no change to the afternoon and evening shifts, with one nurse on duty from 5.00pm until 7.00am as in the opinion of the owners this level of nursing input was sufficient to meet the needs of residents during this time. During this inspection we looked at the nursing staff duty roster for four weeks commencing on 0/06/06. The rosters showed that on 14 of a possible 28 occasions there were not enough nursing staff on duty to meet the minimum staffing levels proposed by the home. The manager’s hours of work were not shown on the rosters for two of the four weeks looked at. During the visit concerns were also identified about the number of care staff on the evening shift, a total of five between 5.00pm and 8.00pm. At the recent residents’ committee meeting residents expressed their frustration at having to wait to go to their rooms after the evening meal. They said they were having difficulty getting attention from staff; they requested a small bell they could use to attract staff attention. Some of the relatives and residents who completed comment cards said that on occasions there was not enough staff on duty. They said the staff worked very hard and were very busy. The home has an induction checklist for new staff; this is not linked to the Skills for Care induction standards. The deputy manager said the Skills for Care induction standards would be introduced later in this year. The home provides a good programme of training. In addition to training on safe working practices topics covered recently have included dementia care, nutritional support for people with eating difficulties, palliative care and the care of with epilepsy. Information provided by the home showed that 75 of care staff have an NVQ (National Vocational Qualification) at level 2 or above. This exceeds the ratio recommended by the National Minimum Standards, which is 50 . The staff files looked at showed that the required pre-employment checks had been carried out before new staff started work in the home. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Overall the home is well managed. The quality survey that was carried out by the home identified a number of areas where residents and relatives felt the service could be improved and the management team must now take appropriate action to deal with issues raised. EVIDENCE: The management structure is clearly defined; the home has a registered manager, a deputy manager, and a general manager. Regular staff meetings are held for all grades of staff and detailed records are kept. The home now has a residents committee; the most recent meeting was in May 2006. Eighteen residents one relative and four staff attended the meeting. The items discussed included food and the availability of staff on the Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 23 evening shift. More information on the staff issue is included in the “Staffing” section of this report. The home has recently issued questionnaires to residents and relatives covering all aspects of the service. The response rate was good, 26 of residents and 50 of relatives replied. The results have been analysed and the report showed that the home had identified actions to be taken in response to some of the areas highlighted. However it was not clear how other areas were going to be dealt with or how the findings of the survey were going to be shared with residents and/or their representatives. The home is planning to issue questionnaires to staff in the near future. The home does not have any involvement with the personal finances of residents. There is a system of staff supervision in place with one to one meetings scheduled to take place every eight weeks. The information provided by the home showed that the necessary systems are in place to make sure that installations and equipment are maintained is safe working order. The housekeeper is responsible for health and safety, this includes making sure bed rails are safe, she was well aware of the safety measures that are needed when bed rails are being used. However the risk assessment forms relating to the use of bed rails do not make it clear why bed rails are being used and do not clearly identify the potential risks. The housekeeper and two other staff are being trained to check portable electrical appliances; an external contractor has done this until now. The accident records did not have enough information about what action had been taken following an accident. The time last seen was not recorded for accidents that were un-witnessed. There is as yet no system for analysing accidents. The housekeeper, in her capacity as health and safety officer, should be involved in the reviewing of accidents. The records showed that one resident had a cocoon bed. This type of bed is a form of restrain but no risk assessment had been done to demonstrate why it was in the best interests of the resident. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 24 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 2 2 X 3 3 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 2 Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15 Requirement The registered person must ensure that the care plan sets out in detail the action, which needs to be taken by staff to meet all aspects of the health, personal and social care needs of the resident. Previous timescales of 31/08/05, 28/04/06, & 16/06/06 not met. Care plans must show evidence of involvement by residents and/or their representatives. Timescale for action 29/09/09 2. OP7 15 29/09/06 3. OP8 17 Sch. 3 Previous timescale of 28/04/06 & 16/06/06 not met. Care plans must show in detail 29/09/06 how residents’ needs in respect of pressure area care, nutrition, falls and specialist health care needs (e.g. Dementia) are being identified and met. Previous timescale of 28/04/06 & 16/06/06 not met. The registered persons must 29/09/06 make sure that the systems for managing medication are safe. 4. OP9 13(2) Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 26 5 OP10 12(4) 6 OP12 16 Previous timescale of 16/06/06 not met. The registered persons must 29/09/09 make sure that the home is run in a way that promotes the privacy and dignity of residents. The registered person must 29/09/06 continue to make sure that residents are given opportunities for stimulation through leisure and recreational activities inside and outside the home, which suit their needs, preferences and capacities. Previous timescale of 30/06/06 not met. The registered persons must make sure that staff left in charge of the home know how to deal with suspicions and/or allegations of abuse. The registered persons must provide the CSCI with evidence of how they are going to manage to meet the needs of residents for the duration of the work resulting in a temporary reduction in the availability of communal bathrooms. This must include information on how residents have been consulted. The registered persons must make sure that the call bells in the communal areas are easily accessible to residents. The registered person must make sure that there are, at all times, enough suitably qualified and competent staff on duty to meet residents needs. The registered persons must provide the CSCI with a detailed report of the actions they are going to take to address the issues identified in the responses to the quality monitoring questionnaires. DS0000042143.V297901.R01.S.doc 7 OP18 13(6) 29/09/06 8 OP21 23(2) 04/08/06 9 OP22 23 29/09/06 10 OP27 18 29/09/09 11 OP33 24 25/08/06 Well Springs Nursing Home Version 5.2 Page 27 12 OP38 17 Sch. 3 13 OP38 17 Sch. 3 The registered persons must make sure that a comprehensive risk assessment is carried out and recorded for all forms of restraint including the use of bed rails and cocoon beds. The accident records must include detailed information on the nature of the accident and the actions taken following the accident. Previous timescale of 16/06/06 not met. The registered persons must provide the CSCI with a written improvement plan. The improvement plan must set out how they intend to make improvements to the service and the timescale within which this will be achieved. 25/08/06 29/09/06 14 *RQN 24 25/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The pre-admission assessment form should be dated and signed and should make it clear who was involved in the pre-admission assessment process. Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Well Springs Nursing Home DS0000042143.V297901.R01.S.doc Version 5.2 Page 29 - 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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