Inspection on 12/02/07 for Welland House

This inspection was carried out on 12th February 2007.

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

Welland House 03/10/08

Welland House 14/11/07

Welland House 18/07/07

Welland House 17/01/06

Welland House 23/08/05

Welland House 14/01/05

Welland House 15/09/04

Welland House 14/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Welland House Poplar Avenue Dogsthorpe Peterborough PE1 4QG Lead Inspector Matthew Bentley Key Unannounced Inspection 12th February 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Welland House DS0000035292.V330574.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. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welland House Address Poplar Avenue Dogsthorpe Peterborough PE1 4QG 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) 01733 345421 01733 563209 cathy.wiseman@peterborough.gov.uk Greater Peterborough Primary Care Trust Cathy Wiseman Care Home 54 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (6), Old age, not falling within any other of places category (48), Physical disability (3) Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Welland House is situated in the Dogsthorpe area of Peterborough. The home is a single storey building which has been purpose-built and offers accommodation to up to fifty-four elderly people of both genders. Built about twenty years ago, the home is divided into six self-contained units, each comprising lounge, dining and kitchen areas, single bedrooms, bathrooms, toilets and a sluice. An extension, registered in 2004, has four single rooms, each with an ensuite toilet, washbasin and shower, as well as a lounge/dining room with a kitchenette area. One of the units offers care to people who have been diagnosed with a dementia. There is a large lounge in the centre of the home, a main kitchen, laundry, offices and staff facilities. The home is set in pleasant gardens and is within walking distance of local shops, pubs and churches, and a few minutes drive from the centre of the city of Peterborough. Good road and rail services link Peterborough to London and other major cities. The fees charged range from £343.19 a week to £413.28. People using the service for respite care are charged £84.00 a day. The reports published by the Commission are available in the entrance hall and individuals can be given their own copy if they request. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out by 2 inspectors on the 12th February 2007 between 11:00 and 15:45 Methods used to carry out the inspection included speaking to residents, staff, and the manager; reading documents, and a tour of the home. What the service does well: What has improved since the last inspection? Provision has been made to ensure that residents have a sufficient supply of medication. The manager feels that staff and the management team are working better as a team, and the kitchen is better able to meet the dietary needs of individuals. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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 Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate information and procedures are available to assist residents in their decision to move into the home. EVIDENCE: The home’s statement of purpose and service user guide are detailed and reflect the services offered. The documents are readily available to residents and relatives. Each service user agrees a statement of terms and conditions with the home so that they know what service they can expect, and what is expected of them. The manager or a senior member of staff gain detailed information about potential residents’ needs, including a visit to meet them to make sure that the home will be suitable for the individual concerned, though some assessments Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 9 were not signed or dated meaning that the person who carried out the assessment could not be identified. The home has a programme of staff training including training in the needs of people with dementia so that the specialist needs of the people living in the home are properly met. New residents are provided with a trial period after which the placement is reviewed. One resident who had moved into the home for a period of respite care had decided to stay and said that, she was happy with her decision. Service users are not referred to Welland House for intermediate care so standard 6 is not applicable to this home. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are insufficient so it is not clear that care staff know how to assist residents, and procedures for managing medication are not being followed, which potentially puts residents at risk. EVIDENCE: Care plans were seen and detailed relevant areas of need, however, detail about how the need was to be met was lacking, so it would not be clear to new, or agency staff what care they needed to provide. A husband and wife live on one of the units, though in separate rooms, but the care plans did not indicate that they were married. Additionally, there was no indication that residents had been involved in the compilation of the plans. A requirement has been made that care plans are updated to better inform staff about the care that is to be provided, and efforts must be made to ensure as far as possible that residents are involved in the compilation and reviewing of the Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 11 plans. Daily recording of what each resident had been doing was insufficient and on some days there was no indication that anything had taken place. The home is provided with a newsletter known as the Residential Rag, which contains articles and information which may be of interest to residents. A senior nurse who is a member of the Primary Care Trust provides training in medication. A number of omissions, errors, and handwritten alterations were present on the records relating to medication. A requirement has been made about this. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a quality of life which they are entitled to expect. EVIDENCE: Residents’ visitors are welcome at the home at any reasonable time, and are invited to any events that take place. Residents and relatives’ meetings take place regularly. The home has a day centre attached to it, and residents said that they use it when events are taking place. Outside entertainers are brought in at the weekend at least once a month and talking books and newspapers are available. Informal one-to-one discussions take place and carers are encouraged to do things with residents though these tend to be in the afternoons as morning shifts are very busy. The catering arrangements at Welland House are excellent. A cooked breakfast is available Monday to Saturday for those who want it, and during the evening, residents are asked to choose what they want to eat for lunch the following day. The kitchen area is very clean and appears well-equipped. Teas are prepared by staff on each unit, which allows for more flexibility with regard Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 13 to timing and choice. One person, who has a particular medical condition, has been provided with a special diet. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s procedures and training mean that residents should be protected from harm. EVIDENCE: The home has procedures for residents or their representatives to follow, should they need to make a complaint about the service; the procedures are included in the service user guide and include the address of the Commission and timescales for responses. One resident said that they would feel able to go to the office if they wanted to make a complaint, but added, “there is nothing to complain about”. The home has an adult protection policy to guide staff in dealing with allegations of abuse or mistreatment, and there is also a whistle blowing policy aimed at encouraging staff to voice any concerns; staff have also received training in the County Council’s adult protection procedures. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an adequately maintained environment, though more attention needs to be paid to eliminating unpleasant odours. EVIDENCE: The home is situated in the city of Peterborough and is close to shops, pubs and other amenities. The main fabric of the home is well maintained with a good standard of décor. Service users have access to a range of safe and comfortable communal areas including lounges, and dining areas. Furnishings and fittings provided, are clean, domestic in scale and design, and appear both comfortable and suitable for their purpose. The majority of areas of the home were clean and comfortably furnished, though one room had a smell of urine; this was Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 16 discussed with the manager who said that the carpet causing the odour will be replaced. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 17 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. 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 this service. Residents receive care from an adequate number of staff who are competent and properly trained and proper procedures are in place to ensure unsuitable people are not employed so that residents are not put at risk. EVIDENCE: Staff members spoken to said that there were sufficient staff to meet the needs of the residents, though they did have to work flexibly across the whole of the home, rather than concentrate on one particular unit. Residents said that they were happy with the staff and it was evident that even though the staff on duty were not employed directly by the home, they had developed relationships with residents, that were warm and friendly. Three waking night staff are on duty overnight from 22:00 until 08:00 and an on call system is in place in case management support is needed out of hours. Staff records were seen, and contained the required documents including proof of identity, two references, and CRB checks. New staff are required to work through a period of induction training so that they get to know how care is provided, how to work safely, and other aspects of working in the home, including treating residents with respect and maintaining confidentiality. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 18 Updates relating to training in health and safety matters are provided every year. A good proportion of the staff have achieved National Vocational Qualifications (NVQs) in care at level 2, and a number of staff are studying to achieve the award at both levels 2 and 3. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is generally good, though there is room for improvement in relation to the supervision of staff. EVIDENCE: Staff members spoken to said that the manager was good and had regular contact with staff and residents. The home operates a ’keyworker’ system, and staff spoken to were clear about what the role entails. Records, and the cash held for residents were in order. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 20 The statement of purpose states that every month a number of ‘themed’ questionnaires are given to a proportion of the residents for them to give their views on, for example, the quality of the food, staff or environment. Staff also regularly asks informally how residents feel about the home. An annual survey of residents and relatives’ views of the service provided takes place, and people who use the service for respite care are given a questionnaire before they leave. Responses from the questionnaires are collated into a report which is published annually. Formal supervision of staff should take place at least 6 times a year; this is not happening for all staff members. A requirement has been made about this. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 22 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 After consultation with the service user care plans must reflect how the service user’s needs in respect of his health and welfare are to be met. Records of the administration of medication must be completed correctly. (Previous timescale of 17/01/06 not met) Failure to meet this timescale may result in action being taken against the service). Timescale for action 31/07/07 2. OP9 17 (1)(a) 12/02/07 3. 3. OP36 OP26 18(2) 16(2)(k) Arrangements must be made for 30/04/07 all care staff to receive supervision on a regular basis. The care home must be kept free 30/04/07 from offensive odours. The carpet in the bedroom identified must be cleaned or replaced, if this is the cause of the odour. Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. Refer to Standard Good Practice Recommendations Welland House DS0000035292.V330574.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Welland House DS0000035292.V330574.R01.S.doc Version 5.2 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. 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!