Inspection on 17/01/06 for Welland House

This inspection was carried out on 17th January 2006.

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 14/11/07

Welland House 18/07/07

Welland House 12/02/07

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 Nicky Hone Unannounced Inspection 17th January 2006 08:30 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 Welland House DS0000035292.V278926.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. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 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 Peterborough City Council Sally-Anne O`Connell 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.V278926.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to three service users aged between 60 and 64 years may be accommodated at any one time These three service users will fall within categories PD and DE only Date of last inspection 23rd August 2005 Brief Description of the Service: Welland House, situated in the Dogsthorpe area of Peterborough, is a single storey, purpose-built home offering accommodation to fifty-four elderly service users. Built about twenty years ago, the home is divided into six selfcontained 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. Set in pleasant gardens, the home 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. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of Welland House for the 2005/6 inspection year. An unannounced inspection was carried out on 23/08/05: to get a complete overview of the service offered by Welland House, the reader should read the reports of both inspections. This inspection started at 08.30 and included a tour of the building, brief discussion with residents and staff, and some time with the manager checking that the requirements made following the last inspection had been met. Before the inspection, questionnaires were sent on behalf of the CSCI to residents and their relatives. Thirty-eight responses were received: seventeen completed by residents and twenty-one completed by relatives. On the whole the responses were reasonably positive, although one resident answered “no” to almost every question, and several relatives felt there are not enough staff. What the service does well: What has improved since the last inspection? All four requirements made following the last inspection have been met. The manager feels that staff are getting better at doing activities with the residents. Welland House DS0000035292.V278926.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. Welland House DS0000035292.V278926.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 Welland House DS0000035292.V278926.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): 2, 3 Each service user now 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. EVIDENCE: Care plans seen contained evidence that a detailed assessment of the person’s needs is carried out before they are offered a place. Files seen contained a copy of the statement of terms and conditions which has been agreed with each resident (or their representative). This document gives clear guidance on what the home will offer, and what is expected of the resident. Welland House DS0000035292.V278926.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 Care plans give detailed information to make sure residents’ personal and healthcare needs are met. Procedures for the administration of medication need further tightening up to ensure residents are safe. EVIDENCE: Care plans seen contained detailed information about the way residents want their need to be met. Monthly reviews of every care plan take place, and changes to care plans are signed and dated. Healthcare needs are identified through the care plans and monitored at the monthly reviews to ensure all needs are met. The manager said that an incident regarding medication had resulted in all policies and procedures being reviewed and updated where necessary. Generally, medication administration records (MAR sheets) had been completed correctly, however, there were some areas where improvement is needed. Staff had recorded that one medication for a resident had not been given for two days because none was available. In one flat a code had been used on medication administration records to indicate why a medicine was not Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 10 given, but there was no explanation of the code. Changes to MAR sheets were not always signed and dated. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 11 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, 15 For the majority of residents the lifestyle they experience in the home is to their satisfaction. EVIDENCE: Staff and the manager said that the number and frequency of activities offered is improving. Residents are able to attend the day centre whenever they want to, and a carer from the day centre will take people out. Eleven of the residents who responded to the CSCI survey said “yes”, the home provides suitable activities (and six residents answered “no” or “sometimes” to this question). The manager said that a lot of activities took place over the Christmas period, which the residents enjoyed. A new assistant manager has been given the task of improving activities as part of her personal development plan. Residents are happy that their visitors are welcome at the home at any reasonable time, and are included in any events that take place. Residents and relatives’ meetings take place regularly. A cooked breakfast is available every day for those who want it, and residents choose during the evening what they want to eat for lunch the following day. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 12 At the time of the inspection, the kitchen was very busy, with staff collecting breakfasts, deliveries arriving and lunch being prepared. But it was very well organised, the kitchen was clean and tidy, and the three staff clearly knew what they were doing. Residents spoken to, and those who responded to the CSCI survey, said that on the whole they are satisfied with the food provided. One person said “it could be hotter”. The home’s quality assurance questionnaires had identified that there is a 90 satisfaction rate for the food: the manager will try to identify and rectify the 10 shortfall. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 13 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): 18 Procedures for the protection of vulnerable adults are given high priority to make sure that residents are kept safe. EVIDENCE: The home follows the adult protection protocol produced by the Greater Peterborough Primary Care Partnership (GPPCP), and the manager is clear about her responsibilities under the protocol. Awareness of abuse is part of induction training for new staff, and all staff attend training in the protection of vulnerable adults: several dates have been arranged during 2006 to ensure that all staff have attended this training. The manager said that all the managers of GPPCP’s homes for older people will be taking a 3-day course so that they will be able to deliver POVA training. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 14 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, 26 Residents live in a clean, comfortable and reasonably well-maintained environment, although some areas will soon need refurbishment. EVIDENCE: One of the courtyard gardens has been landscaped by a group of staff who raised the funds and carried out the work themselves. The area is now an attractive and pleasant place for residents to spend time. A second courtyard garden has been started: so far, a fence has been erected to make the garden safe, the low walls have been painted and landscaping will take place in the spring. All areas of the home seen were clean and comfortably furnished, although scuffed paintwork is beginning to make some areas look a little shabby: the manager must ensure that the programme of re-decoration continues. Some of the corridor carpets are looking worn and stained: consideration must be given to a programme of replacement. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 15 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, 30 Staff are well trained and competent to meet the needs of the residents. Comments made indicate that numbers of staff on duty might not be adequate. EVIDENCE: The manager said that staff recruitment and retention has been good recently, so the home is almost fully staffed. She said that a recent annual survey of dependency levels of the residents had identified that the home has adequate staff, although one staff member and 10 of the 16 relatives who responded to the CSCI survey said that there are not always enough staff on duty to meet the needs of the residents. One person commented “Staffing levels are definitely worse since NHS has taken over. All staff/bank staff are always rushed and have little time for that very important individual chat or talk especially if the resident needs time to express themselves”; and another wrote “staffing levels very poor, particularly at night”. The manager must take these views into account, and review the staffing position. One member of staff spoken to said that training offered to staff is excellent. Each staff member has their own rolling timetable of training: she was about to undertake a refresher course on moving and handling on the day of the inspection. One staff member said that she had handed all her work in and was waiting to hear if she has been awarded the National Vocational Qualification (NVQ) level Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 16 2 in care. According to the manager, eleven of the care staff have gained this award. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 17 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 Residents’ views are sought and acted on. The system of safekeeping of residents’ money is effective. EVIDENCE: A newsletter “The Residential Rag” is produced for all six GPPCP homes. The copy seen had an explanation about the way the home obtains service users’ and relatives’ views on the quality of the service offered. The results of questionnaires are collated into a report which is available in the home. Since the last inspection, the system for safekeeping of residents’ money has changed. Records of individual transactions were seen (not checked) and the inspector is satisfied that this is a system which ensures that each person gets their full entitlement. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 18 Welland House managers complete notifications of events in the home, and fax these to the CSCI, as required by regulation 37. A representative of the provider carries out unannounced visits to the home, and completes a detailed report, as required by regulation 26: the reports are sent to the CSCI as required. Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 19 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 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 3 X Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 20 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. 2. Standard OP9 OP9 Regulation 13(2) 13(2) Requirement Records of the administration of medication must be completed correctly. An adequate supply of medication prescribed for residents must be available at all times. A programme of replacement of carpets identified as in need of replacement must be drawn up and submitted to the CSCI within the timescale. A programme of redecoration of areas of the home identified as being in need of redecoration must be drawn up and submitted to the CSCI within the timescale. The registered person must carry out a review of staffing levels and ensure sufficient numbers of staff are on duty at all times to meet the needs of the residents Timescale for action 17/01/06 17/01/06 3. OP19 16(2)(c) 28/02/06 4. OP19 23(2)(d) 28/02/06 5. OP27 18(1)(a) 28/02/06 Welland House DS0000035292.V278926.R01.S.doc Version 5.1 Page 21 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.V278926.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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. 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