Inspection on 23/08/05 for Welland House

This inspection was carried out on 23rd August 2005.

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 12/02/07

Welland House 17/01/06

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 Shirley Christopher Unannounced 23rd August 2005 @ 10:40 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 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 I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Welland House Address Poplar Avenue Dogsthorpe Peterborough PE1 4QG 01733 345421 01733 563209 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Peterborough City Council Mrs Sally OConnell Care Home 54 Category(ies) of Older People not falling within any other registration, with number category (OP) 48 of places Dementia (over 65 years) (DEE) 6 Physical Disability (PD) 3 Dementia (DE) 3 Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to three service users aged between 60 and 64 years may be accommodated at any one time. 2. These three service users will fall within categories PD and DE only. Date of last inspection 14 January 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 I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of Welland House for the 2005/6 inspection year and was unannounced. The inspection was carried out by two inspectors and lasted just under two and a half hours. After a tour of the building, one of the inspectors spent time with the manager, checking compliance with the requirements made at the last inspection. The second inspector spoke to six staff and eight service users. Two further members of staff had come in on their day off to work on the newly transformed courtyard garden, which staff had collectively fundraised for and designed, creating a pleasant, safe space. No visitors were met during the course of the inspection. Lunch was observed as it was served up. What the service does well: What has improved since the last inspection? Care staff are to be congratulated on the hard work that has gone into relandscaping one of the courtyard gardens. They carried out fund-raising and did all the work to make the garden into a very attractive, pleasant and safe place for the residents to sit. The home has organised a holiday for the first time in many years: eight residents are going to a hotel in Blackpool. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 standard(s) 2 and 6 The home does not have a statement of terms and conditions, so potentially service users do not know what they should expect from the home, and what the home expects from them. Standard 6 is not relevant to this home. EVIDENCE: The home does not have a statement of terms and conditions which is agreed with residents or their representatives. The manager said that a statement of terms and conditions of residence had been drawn up but was still being discussed. This issue has been outstanding in all Peterborough local authority homes since April 2002 when the Care Homes Regulations 2001 became law. The CSCI has written to the Responsible Person regarding this, and is seeking legal advice. Welland House does not offer an intermediate care service. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 standard(s) 10 Staff practices ensure that residents are treated with dignity and respect and their privacy is upheld. EVIDENCE: Warm, caring, respectful relationships were observed between residents and staff. In discussion, no residents raised any concerns about privacy issues. Feedback from residents about the care staff was mainly positive: one resident felt that some of the care staff did not have the right aptitude, but did not explain this further. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 10 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 standard(s) 12, 14 and 15 Residents are assisted to take control and make choices about the way they want to lead their lives. Meals offered are good. Not enough activities are offered for residents to be kept adequately occupied. EVIDENCE: Eight residents were spoken to about their experiences of living at the home. One resident had lived at the home for fifteen years, whilst others had been at the home for just a couple of weeks receiving interim care. Residents were satisfied with the standards of care and stated that care staff offered choices in daily routines. A key worker system is in place and several residents said that their key worker had taken them out for a walk or purchased small items of shopping for them. One gentleman said that he got bored in the home, whilst another said that he watched television mostly only coming out of his bedroom for meals. Another lady said that she had attended several social events recently including a pub lunch and the Crowlands show. She did not feel well enough to go out at the moment. A number of residents were aware of residents’ meetings but did not attend them. One lady said that regular social events are held, care staff often do her nails and the hairdresser visits weekly. The day centre is used for different activities in the evening and on special calendar events, and residents are welcome to join in whatever is going on in the day centre during the day. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 11 The manager said that activities undertaken are discussed daily at staff handovers and recorded. However, the records of activities undertaken were poor: from the record it appears that very little activity is offered. In one flat, it was recorded that one resident walked round the garden on 29/07/05 and again on 07/08/05: there was nothing else recorded during that two-week period for that person or for any of the other residents of the flat. A holiday has been arranged for the first time for many years. Eight residents are looking forward to spending a few days at a hotel in Blackpool. The hotel is “geared up for people with disabilities” and provides meals and evening entertainment. Five staff will accompany the residents. Lunch was served at around 12.30pm and residents confirmed that they are offered a choice of food. There are two main meals to choose from, or other meals such as jacket potatoes, salads, omelettes and so on. Residents and staff described the food as very good and said residents can choose to eat in the dining rooms, or in their own bedroom. Salt/ pepper and sauce were laid out on the tables. Residents had cold drinks close to hand in the lounges as well as in their bedrooms. Staff said that a cooked breakfast, for example tomatoes on toast, scrambled egg, bacon sandwich and so on, is offered every day, with a full cooked breakfast offered twice a week. Tea is prepared by the care staff and residents can choose whatever they like. There is always cake for tea which is usually home-made, and every resident is given a decorated cake on their birthday. Special birthdays are celebrated by a party tea. The kitchen was inspected and was very clean. The cook reported that the Environmental Health Officer had carried out an inspection 2/3 weeks previously and had said it was a very good kitchen. The majority of the raw food used for the meals is fresh (including fresh, ready-prepared vegetables), which is delivered several times a week. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 12 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 standard(s) 16 Residents know how to make a complaint. EVIDENCE: A number of residents said that they are able to go to the manager if they have any concerns. The home has a complaints procedure. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 13 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 standard(s) 19, 20, 25 and 26 Residents live in a comfortable, well-maintained home which is clean and mostly odour free. EVIDENCE: The parts of the home inspected were generally satisfactory, with no obvious hazards or refurbishment issues identified. In the unit providing interim care, the bedroom windows were wide open, as it was a hot day, but did not have window restrictors on. The member of staff working on the unit confirmed that the windows are locked shut at night. However it was felt that residents and their possessions were vulnerable, despite CCTV fitted around the outside of the home. The home was cleaned to a high standard of cleanliness but a number of areas smelt quite strongly of urine, despite the obvious attempts to keep the home clean. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 14 A further concern was the lack of storage space for aids and adaptations including wheelchairs, which were stored in communal areas of the home. A few bedrooms were inspected and were decorated to a reasonable standard and furnished appropriately. Additional chairs for visitors were not available in residents’ bedrooms but are available elsewhere if needed. The parking area at the front of the home has been re-organised in an attempt to alleviate the problems discussed at the last inspection. There is now a dropoff point, and designated parking for the day centre vehicles. The person who raised the concerns no longer visits the home. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Adequate numbers of staff, properly recruited and appropriately trained, are available to make sure that the needs of the residents are met. EVIDENCE: The manager reported that recruitment of staff has been good, with interviews already completed to fill the posts of three staff who left recently. Agency staff are now only used to cover staff holidays and training. Criminal Record Bureau checks for all new staff were seen. Six care staff were spoken to and all had been working at the home for some time, ranging from one to seven years. One newer member of staff confirmed that she was shadowed for approximately two weeks when she first came into post and was assessed for her competence, before being asked to administer medication. All the staff spoken to stated that the training opportunities in the home were good in terms of both the mandatory training and the NVQ programme. Some staff had completed training provided by the Isle College in Wisbech, including infection control and the administration of medication. All staff spoken to had completed training in the protection of vulnerable adults and one staff member was about to do a further three-day course. Staff stated that they had completed a recent in-house, internal fire course, which involved practical demonstrations. In addition to this, care staff stated that courses meeting specialist need are provided as identified. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 16 The manager said that currently 7 staff are working towards NVQ level 2 in care, and 8 staff have already gained the award. There is a new intake every 6 months, with 3 staff being offered a place each time: the manager has calculated that, providing the trained staff do not leave, the home will achieve the 50 of staff on duty required by the National Minimum Standards, by the end of 2006. 6 places on NVQ level 3 will be offered across all 6 homes in September 2005. Care staff confirmed that they are key-workers to specific residents and usually work on designated units unless the home is short of staff and they are doing overtime. They stated that staff and residents are involved in the implementation and review of the care plans. One member of staff confirmed that when she was first employed at the home, she was shadowed by a more senior member of staff for at least two weeks, and completed all her mandatory training within the probationary period. She was not permitted to administer medication until she and her supervisor felt she was competent to do so. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 36 and 38 Residents benefit from a qualified manager who is supported by a management team dedicated to improving standards, and a well supervised staff team. Health and safety is given high priority. EVIDENCE: The manager is to be congratulated on achieving the Registered Manager Award: she is hoping to do NVQ level 4 in care soon so that units she has already gained will count towards the award. Care staff spoken to stated that all the senior management team were supportive and operated an open door policy. Regular supervision was available both informally and through more formal mechanisms. Residents finances were discussed. One bank account is operated, with individual transaction records for each resident. There was no bank reconciliation being carried out. This arrangement does not adequately protect Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 18 residents’ finances: the inspector has written to the City Council regarding the unsuitability of this arrangement. Care staff spoken to said that they are supervised regularly by senior staff and are able to approach them with any concerns or issues they might have. Resident/relative meetings are held and staff meetings are also held. Care staff confirmed that a meeting was scheduled for the day after the inspection and they had attended a full staff meeting once this year. Unit meetings are held more frequently and staff meeting minutes were said to be available, although not inspected. Staff records now contain a photograph of the staff member. The requirement for the fire doors in the new extension to be held open correctly has been met, and certificates to confirm testing of systems and equipment (for example gas, electricity, hoists and so on) are now available in the home. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 x x x x 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 Standard No 16 17 18 Score 3 x x 3 3 x x 2 3 x 3 Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 20 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 2 Regulation 5 Requirement A statement of terms and conditions of residence must be agreed with each service user. This was a requirement following inspections on 15 September 2004 and 14 January 2005: the timescales were not met The range and amount of activities offered to service users must be improved All areas of the home must be kept free from offensive odours Appropriate arrangements must be put in place for the safe keeping of money belonging to service users Timescale for action 31 October 2005 2. 3. 12 26 16(2)(m and n) 16(2)(k) 31 October 2005 On receipt of this report and ongoing 31 October 2005 4. 35 16(2)(l) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 19 Good Practice Recommendations It is strongly recommended that window restrictors are fitted to all downstairs windows so that service users and their belongings are protected from people who may try to I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 21 Welland House enter the building from the grounds. Welland House I53 I03 S35292 WELLAND HOUSE V242958 230805 STAGE 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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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