Inspection on 14/11/07 for Welland House

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Welland House 03/10/08

Welland House 18/07/07

Welland House 12/02/07

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 Dragan Cvejic Unannounced Inspection 14th November 2007 09:00 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.V355905.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.V355905.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 Mrs Catherine Wiseman Care Home 54 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (17), Old age, not falling within any other of places category (37), Physical disability (3) Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2007 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. The home recently extended their ability and increased a number of people with dementia that were looked after in the home. The home was also offering respite care. 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 en-suite toilet, washbasin and shower, as well as a lounge/dining room with a kitchenette area. There is a large lounge in the centre of the home, a main kitchen, laundry, offices and staff facilities. A part of the building is used as a day centre that is not run from the home and has different staff and management. 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 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.V355905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It included collecting information through regular reports of the responsible individual who visited the home monthly. The home carried out a self-assessment, AQAA that was used in this report. Ten service users, relatives and staff filled in questionnaires and their comments were also considered during the inspection. Still, the main source of information was the site visit, when we spoke to several service users, visitors, staff and the management. We also checked documentation, including service users’ and staff files. What the service does well: What has improved since the last inspection? The home responded to the requirements set on the previous inspection The care plans were reviewed and the style of entries was improved since the last inspection. Language used in care plans was adapted so that there were no embarrassing entries even for users whose care included more intimate personal care. The service users’ file were prepared in a more consistent way, allowing better access to necessary information about each individual. The home ensured that the equipment needed for care was obtained, including sit-on scales, so that service users’ weight could be better monitored. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 6 Changing medication supplier and improving records and procedure for administering medication reduced a number of mistakes and ensured better protection of service users. Two new mobile phones obtained by the home accommodated users now to use phones from their bedrooms to contact their relatives. Recruitment brought more permanent staff to work in the home, but, although it had reduced, had not eliminated the engagement of agency staff. 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.V355905.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.V355905.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): 3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate pre-admission assessment helped the home and potential service users decide on the suitability of the placement for each individual and facilitated an informed decision of service users to move into the home as permanent service users. EVIDENCE: The home carried out an appropriate initial assessment for all new referred service users. The assessment included physical, mental, social and cultural needs in sufficient detail, allowing the home to determine if the assessed needs could be met. The manager wrote to the service users confirming the home’s ability to meet these needs and a copy of the letter was kept in each file, as seen in 4 checked users’ files. The questionnaires filled in by relatives confirmed that the choice of home was given to all users. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 9 The manager identified needs for a better assessment of respite users and was planning to improve this procedure. Trial periods were used successfully, not only to the home’s benefit, but also to allow users to get a taste of life in the home and make an informed decision. Welland House DS0000035292.V355905.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): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Healthcare was significantly improved since the last inspection and users were better protected with new medication procedure, but the engagement of the agency staff still affected continuity of care and satisfaction of service users. EVIDENCE: Care plans were reviewed and improved in terms of the language in which each entry was made. Three checked files showed entries in the first person, making care plans belonging to each individual user. For example the entry about preferences stated: “I prefer skimmed milk in my tea.” Care plans were reviewed monthly and were related to the risk assessments and moving and handling assessments. Care plans were signed either by service users, or by their relatives, as seen in three checked files. Introducing a “Brief Care Plan” summary helped staff and agency workers getting basic information about individuals in a short time, or directing them to read the full version of the needs when there was a need for specific Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 11 intervention. Also, keeping a copy in each bedroom made information more easily accessible to agency workers and carers. Health care of service users was well organised. The files checked, demonstrated a detailed approach to healthcare needs. An example was seen in the file where there was a concern regarding users’ weight. A weight chart was introduced. When there was a significant change recorded, in September, a dietician was called in to determine the best possible way forward. Another example related to a user who was prone to pressure sores and whose plan stated: “Not to lay on her L side, to prevent bedsores.” The medication provider was changed and the system changed from weekly to monthly. Medication was now delivered in blister packs and reduced the potential risk of mistakes. Medication records for four service users were checked and were accurate. Controlled drugs were treated according to the Medicine Act, stored securely and recorded accurately. The home did not currently record medication brought forward from sheet to sheet and this created a more difficult auditing system. Privacy and dignity of service users was much better respected since the last inspection, particularly by permanent staff. However, some agency staff still failed to learn sufficient details about individuals they were working with. This was seen in comments form 4 out of 9 service users’ questionnaires. The manager planned to improve palliative care and had a clear plan of how to achieve better respect for users that were approaching death. Welland House DS0000035292.V355905.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users could enjoy choices regarding activities, food and community contacts, as well as having their wishes, likes and dislikes respected. EVIDENCE: Service users could choose the daily routine in the home. A user stated: “I can go to bed and get up when I want. I prefer sometimes not to join activities and this is respected.” The manager commented in the home’s self-assessment: “We are proud of our fundraising activities. We managed to raise funds and send 9 service users on holiday.” Many visitors were in the home during the site visit and were with their relatives, welcomed into the home, but not disturbing other users. Service users autonomy was promoted. A staff member patiently followed a slow walking user through corridor, talking nicely to her and showing respect for her efforts to maintain independent mobility, while still monitoring her for safety. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 13 Most questionnaire respondents judged food and mealtimes as very good. One indicated that the food was getting cold in some cases, but the manager explained that the home was fully aware and had already addressed the problem. She stated that the food trolley was faulty and was replaced since. The choice was available and the food was nutritious. Users preferences, likes and dislikes were respected. Welland House DS0000035292.V355905.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 adequate. This judgement has been made using available evidence including a visit to this service. The home improved protection of service users by acting when allegations were made; ensuring users’ financial interests were protected and preventing potential abuse by clear policies and preventative procedures. However, service users’ possessions, such as items of furniture brought into the home, were not recorded and did not ensure protection from potential materialistic abuse. EVIDENCE: The home had a clear complaint procedure and several users spoken to stated that they knew how to complain if they wanted to. A visitor also stated that she would know how and to whom to complain. The manager stated that the home had not received any complaints. No complaints were made to the CSCI either. The AQAA stated that the past 6 complaints were responded within the set procedure and were not upheld and complainants were satisfied with the outcomes. The home made 5 referrals for investigating potential inclusion on POVA list, but, apart from the two cases currently under investigation, no one was referred to POVA records. The management of the home was cooperating with the Adult Protection Team and multi-agency group that was investigating 2 separate allegations about potential incidents of abuse by agency staff on service users in the home. Good Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 15 cooperation showed the home’s determination to protect service users. Also, the workers in question were not engaged to work in the home until all issues were checked and investigated. Some service users needed help with their finances, and families and social services were dealing with them. Some others wanted the home to help them and this was organised through the PCT system. All records and amounts checked were accurate and correct. However, the home did not keep updated records of service users’ possessions brought into the home. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 16 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in an adequately maintained environment, where regular maintenance ensures comfort for users is monitored and acted upon when there is a need or when regular replacements take place. EVIDENCE: A tour through the home during the site visit, the questionnaires returned, comments from 4 service users and a visitor during the site visit indicated users’ satisfaction with the environment. New carpets in corridors, redecorated lounges, as well as good response from the property services to any issue regarding maintenance, ensured that the home offered a comfortable and pleasant environment to service users. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 17 Hoists were kept in the area where the phone was, but introduction of two cordless phones recently obtained allowed users to phone from their rooms if they wanted to. This innovation improved respect for privacy and allowed less mobile users to more easily use the phone facility. The home used CCTV to improve the safety of the home in a non-intrusive way; only the front entrance and the grounds around the building were covered by cameras, retaining privacy for users whilst improving the general safety of the building. As some users started developing dementia, it was identified that a sensory room would help, and the manager presented plans to equip the sensory room in the coming year. Infection control measures were in place and were emphasised through recent staff training. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. The home’s permanent staff offered good quality of care, but the agency workers engaged to cover for absences did not know users well enough to ensure continuity of good care and achieve satisfaction among service users. EVIDENCE: The home had recently carried out a new recruitment drive and recruited 4 more staff. Although the staff ratio was appropriate, some absences due to illness and maternity put the home in the position to have to use agency staff. The manager tried to engage the same agency workers on a continuous basis, but service users felt that there was a difference in quality of work between permanent staff, who they thought were excellent, and agency workers, who could not offer continuity of care and the same effectiveness. Four out of nine users questionnaires indicated lower standards when agency workers covered shifts. Staff were much better organised and the manager’s action to clarify priorities seemed to give significant improvements in the response time to users’ calls and better protection of service users. However, the majority of responses to staff related questions could be summarised as “usually”, rather than “always”. Recruitment was carried out appropriately and files checked confirmed that all necessary checks were carried out prior to staff starting work with service Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 19 users. The staffing complement was recently increased based on the increased needs of service users who had started developing dementia. The home achieved the minimum of 51 of staff holding NVQ 2 and 3 qualifications and regularly attended up-dates of all mandatory training subjects. Induction for new staff was carried out using the Skills for Care induction programme. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Day to day management of the home was improved, and consequently service users were better protected by safe working practices. EVIDENCE: The manager completed her NVQ 4 and Registered Manager’s Award training. A quality assurance review was organised and carried out within the PCT. Results were sent to the CSCI, indicating potential areas for improvement, as identified by the home themselves from the analysis of collated comments. The home helped several service users with their personal allowances. However, when representation of users regarding their finances was necessary, either families, or Social services, were asked to become appointees, as Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 21 declared in the AQAA and seen during the site visit. Records of all transactions were accurate. Staff supervision was brought up to date and provided regularly, ensured good support to staff and, consequently, a better standard of care. The respect for individuals and better understanding of users’ conditions was a result of training and proper and regular supervision. The home also improved in the area of safe working practices. The home had recently been inspected by Environmental Health. Recent infection control training also improved protection of service users. Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 22 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 Requirement Medication brought forward from sheet to sheet must be recorded on the current sheet to allow easy audit and improve protection of service users. The agency workers must be better inducted, must know the details of the users they are helping, improve continuity of care and reduce frustration and dissatisfaction of service users. Service users’ personal possessions, including furniture, brought into the home must be recorded and records kept up to date, to ensure full protection of users’ rights and valuables. Timescale for action 30/01/08 2 OP10 12 30/01/08 3 OP18 Schedule 4 30/01/08 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.V355905.R01.S.doc Version 5.2 Page 24 Welland House DS0000035292.V355905.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Inspection Team 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. 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