Inspection on 21/02/06 for Well Springs Nursing Home

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20/06/06

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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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 21st February 2006 09:45 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.V284501.R01.S.doc Version 5.1 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.V284501.R01.S.doc Version 5.1 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 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 (1), Terminally ill over 65 years of age (3) Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The one place for TI category is for the service user named in the NCSC letter dated 10 December 2003. 14th June 2005 Date of last inspection Brief Description of the Service: Well Springs provides nursing care for 52 male and female service users, 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 based 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. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of this home and it was unannounced; the first inspection was announced and took place in June 2005. Two inspectors carried out the inspection between 9.45 am and 4.15pm. There have been no additional visits to the home since June 2005. The methods used during the inspection included talking to residents, visitors, staff and management. We looked at records and carried out a partial tour of the home. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are discussed with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection? The home now has a residents’ committee and together with the management team they are looking at ways to continue to improve the opportunities for social and recreational activities both inside and outside the home. The home now has residents meetings. The menu of the day is displayed on the residents’ notice board and in the dining room, lunch is still a set menu but the manager said residents are offered a choice of vegetables. Alternatives to the main course are available. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 6 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.V284501.R01.S.doc Version 5.1 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 Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 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): These standards were not inspected on this visit, for details please refer to the report dated 14 June 2005. EVIDENCE: Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 9 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 Despite the fact that residents and relatives said they were satisfied with the care the records did not provide evidence that residents’ health care needs were being met appropriately. Some medication practices create the opportunity for residents to be put at risk. EVIDENCE: The purpose of the care plan is to set out how the needs of each individual resident, identified during the assessment process, will be met. The care plan then becomes the yardstick for judging whether appropriate care is being delivered. The care records of four residents were looked at. The care plans did not set out in detail how residents’ personal and health care needs would be met and did not show that appropriate care was being delivered. Care plans for people with specific problems such as dementia and Parkinson’s did not show how these illnesses affected their day-to-day lives or what assistance they needed from staff. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 10 The risk of developing pressure sores is assessed using a recognised assessment tool (Waterlow). However when residents were identified as being at risk there were no plans to show how this risk would be managed. There was some evidence that turn charts were used. The care plans for the treatment of wounds and/or pressure sore did not show any evidence that the home uses a grading system to monitor the progress of wounds/pressure sores or the effectiveness of treatments. It was not clear who was responsible for deciding which wound dressing should be used or why particular dressings were chosen. Nutritional risk assessments were not in place for residents with identified needs in this area. The recording of residents’ weights was not done consistently; in some cases there were gaps of several months. Two residents had problems with eating, one with swallowing and one with chewing but neither had a care plan in place to tell staff how to deal with this. Although falls diaries were in place for some residents’ falls’ risk assessments were not done. There were no plans in place to say how the home would deal with the risk of falling. Continence assessments had been done but the information from these assessments had not been used in the care plans. For example there was nothing in the plans to say which incontinence products the residents needed. Two of the records showed that resident were presenting with behaviour, which was challenging, there were no care plans in place to guide staff on how to deal with this behaviour. There was no evidence of involvement by residents or their representatives in the care plans seen. Relatives spoken to said they were not aware of the care plans but one said they were kept informed about changes in their relative’s care needs. Care staff said they did not have any involvement with the care plans. The home has recently introduced a new system for medicines. The supplying pharmacist provided training before the system was introduced. A random selection of controlled drugs was checked and was correct. None of the residents in the home were administering their own medication. There were some gaps on the medication administration charts meaning that it was not possible to tell if medicines had been given or not. Some medicines that had been signed for had not been given. This is not good practice. There were no photographs of residents. The home has changed its system for disposing of medicines to comply with recent changes in the law. The medicine policies and procedures were out of date but the deputy manager Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 11 said new policies and procedures had been obtained and were about to be implemented. Two nurses have recently attended training on medicines and the remaining nursing staff are booked on courses over the next few weeks. Requirements have been made about these standards. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 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 & 14 The home provides a good range of in-house social activities and is working towards providing more opportunities for people to take part in social events outside the home. EVIDENCE: Since the last inspection the home has continued to develop the range of activities provided for residents. During the morning residents were seen playing board games in the dining room and there was an exercise/music session in the afternoon. Social care plans have been developed and a new format is being introduced to record residents’ participation in social events. One relative said more attention was needed to meet the social interests of male residents. The home now has a residents committee, residents elected the members. This is good practice. There are regular meetings between the committee, staff and management where ideas and suggestions for activities and events are discussed. Some residents are able to go out alone or with their families. However many of the residents are unable to go out without assistance from staff and the home is working towards providing this group of residents with more opportunities to take part in external social events. Seven residents recently went to the theatre in Bradford. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 13 There are no restrictions on visiting and visits can take place in private. Residents are encouraged to bring their personal belongings with them when they move into the home. The home is working towards creating a culture, which promotes the independence of residents and supports them in exercising choice and control over their lives. However in order to be able to demonstrate this the home must address the issue of involving residents and/or their representatives in the care planning process. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 14 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 Overall complaints are dealt with appropriately despite the fact that this is not always fully supported by the complaint records. EVIDENCE: The home has a complaints’ procedure. The home keeps a record of written complaints but does not record verbal complaints. The manager said the home had received one complaint since the last inspection; this had been referred from the CSCI and had been dealt with by the home. Information about another complaint was found while looking at staff files. The complaint concerned a member of staff and had been dealt with by the home but there was no record of it in the complaints file. Comments from relatives about the complaints procedures varied, some were aware of how to make a complaint while others were not sure how they would raise any concerns. A requirement has been made about this standard. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 15 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): These standards were not inspected on this visit, for details please refer to the report dated 14 June 2005. EVIDENCE: Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 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, 28 & 29 There are not enough nursing staff on duty on the evening and night shift to make sure that residents nursing care needs are properly met. There are not enough staff on night duty to make sure that residents’ needs are met. Robust recruitment procedures are not consistently followed and this potentially puts residents at risk. Staff are provided with opportunities to develop their knowledge and skills. EVIDENCE: The manager said that staffing levels had been increased since the last inspection; there are now more nurses on the morning shift, however there is only one nurse on duty between the hours of 4.00pm and 7.00am. While the numbers on day duty may be adequate the skill mix on the evening and night shift is not, the ratio of 1 nurse to 52 residents is not sufficient to ensure that nursing care needs will be met. The home has four staff on night duty, (one nurse and three care assistants); even allowing for the one-hour overlap of day and night staff (between 7.00am and 8.00am) this is not sufficient. Staff said they enjoyed working at the home, they felt it had a good atmosphere and residents were given “good” care. They said they thought residents would benefit if there were more staff available to spend more quality time with them. Relatives said staff were attentive but there were times when there were not enough staff available. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 17 The National Minimum Standards recommend that 50 of care staff should be qualified to NVQ level 2. The home has 54 of its care staff qualified to NVQ (National Vocational Qualification) level 2 or above, this figure includes approximately nine staff who have achieved NVQ level 2 and level 3 The home provides a good training programme. Care staff said they thought they would benefit from having more training from the nurses about how to meet the particular needs of the residents in the home. References had been obtained before new staff started work in the home but there was concern about the quality of the pre-employment vetting procedures. The files of two recently appointed nurses showed that both nurses had been dismissed from previous posts, there was nothing in the files to show that the home had checked this information or the reasons for the dismissals before employment commenced. The home checks nurses registration with the NMC (Nursing and Midwifery Council) using the on line service and keeps a record of nurses’ registration details. The home has a recruitment checklist in the files, this showed that CRB (Criminal Record Bureau) checks had been done but did not show the level of disclosure. In one of the files a CRB check from a previous employer had been accepted but a POVA (Protection of Vulnerable Adults) First check had not been done before the person started work in the home. Requirements have been made about these issues. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 18 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): 33, 35 & 37 The inspection identified concerns about the way in which the health care needs of residents are dealt with and concerns about staffing arrangements. In order to be able to demonstrate that the home is run in the best interests of residents the management team must address these concerns. EVIDENCE: Informal residents meeting are held every week and more formal meetings are held about every three months. A member of staff attends the residents’ committee meetings so that any issues can be highlighted and communicated to the management team. The manager said questionnaires had been prepared for residents, relatives and staff but had not yet been sent out, they are due to go out in March and the plan is that they will then be issued every March. Staff said they had confidence in the management team and they were approachable. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 19 The inspection identified a number of concerns about record keeping; specifically in relation to residents care records, medication records and the complaints records. More details are provided in the relevant sections of this report. Requirements have been made about these issues. The administrator said the home does not manage residents’ finances and does not act as appointee or agent for residents. Small amounts of spending money are held on behalf of some residents, records are kept of all transactions and receipts are available. These records were not looked at; this will be followed up at the next inspection. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 1 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 2 X Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 21 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 timescale of 31/08/05 not met. Care plans must show evidence of involvement by residents and/or their representatives. Care plans must show in detail how residents’ needs in respect of pressure area care, nutrition, falls and specialist health care needs (e.g. Dementia) are being identified and met. The registered persons must seek advice from the Tissue Viability Nurse regarding the treatment of all residents in the home with a pressure sore or wound. The registered persons must make sure that the systems for managing medication are safe and that the required records are kept up to date and accurate. Timescale for action 28/04/06 2 3 OP7 OP8 15 17 Sch. 3 28/04/06 28/04/06 4 OP8 13 01/03/06 5 OP9 13(2) & 17 Sch. 3 28/04/06 Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 22 6 7 OP9 OP12 17 Sch 3 16 8 OP16 22 & 17 Sch. 4 9 OP27 18 10 OP29 19 11 OP33 24 The home must have a photograph of every resident. The registered person must continue to make sure that residents are given opportunities for stimulation through leisure and recreational activities outside the home, which suit their needs, preferences and capacities. The registered persons must keep a record of all complaints that includes information on the action taken in response to the complaint. The home must maintain a summary of all the complaints received so that this information can be provided to the CSCI on request. The registered person must review the staffing levels and ensure that sufficient staff are on duty at all times to meet the assessed needs of residents. Previous timescale of 31/08/05 not met. This must include a review of the skill mix. The registered person must ensure that all the information specified in Schedule 2 & 4 (6) is obtained before the employee starts work in the home. Previous timescale of 31/08/05 not met. The registered persons must implement a system for quality assurance and quality monitoring based on seeking the views of service users. The findings of the quality assurance survey must be made available to service users. 12/05/06 30/06/06 28/04/06 14/04/06 14/04/06 30/06/06 Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 23 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 OP12 OP16 Good Practice Recommendations The social activities programme should take account of the social interests of male residents. The home should make sure that all residents and their representatives are given information about the complaints procedure. Well Springs Nursing Home DS0000042143.V284501.R01.S.doc Version 5.1 Page 24 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.V284501.R01.S.doc Version 5.1 Page 25 - 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. 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