Inspection on 22/11/05 for Wellburn House

This inspection was carried out on 22nd November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellburn House 22/06/07

Wellburn House 04/07/05

Wellburn House 14/12/04

Wellburn House 27/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Wellburn House Main Road Ovingham Northumberland NE42 6DE Lead Inspector Deborah Haugh Announced Inspection 22nd November 2005 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 Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 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. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wellburn House Address Main Road Ovingham Northumberland NE42 6DE 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) 01661 834522 01661 839420 Wellburn Care Homes Limited Mrs M Armstrong Care Home 33 Category(ies) of Past or present alcohol dependence (1), Old registration, with number age, not falling within any other category (32) of places Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 6 elderly residents may also be suffering from dementia 4th July 2005 Date of last inspection Brief Description of the Service: Wellburn House is a two storey detached property located in a quiet residential area on the outskirts of the village of Ovingham. Ovingham has a local shop, 2 public houses and bus services operate. The home has a pleasant garden surrounding the building and many bedrooms have rural views. Wellburn House is registered to provide residential care for frail older people and older people with dementia Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 22/11/05 from 9.00am until 1pm. The Registered Manager, Margaret Armstrong was on duty during the visit. Wellburn Care Home is being refurbished and building works are in the process of improving the facilities. There were 27 service users at the time of the visit. Prior to the inspection questionnaires were provided to service users and relatives. Service users completed 16 questionnaires and they also shared their views during the inspection. Time was also spent observing the contact between the service users and staff. Relatives completed 23 questionnaires and they were asked for their views during the inspection. Three care plans were examined. Arrangements for the administration and management of medication, nutrition, recruitment, staff induction and training were checked. Arrangements for the Protection of Vulnerable Adults were examined such as service users finances; staff whistle blowing and quality assurance. What the service does well: Wellburn House has a homely atmosphere. Improvements to the premises continue. The new lounge area is appreciated by the service users, visitors and is used for a range of activities. All of the service users said they liked living at Wellburn House, felt safe, liked the food and felt that staff treated them well. Service user comments included - ‘I’m happily involved in the home.’ -‘Quite happy.’ -‘Life is good at Wellburn.’ - ‘Overall I am happy here, the staff are good to me.’ - ‘Staff do very well!! Helpful. I enjoy the outings. General atmosphere is very friendly.’ - ‘I like Wellburn’s situation. Good company – new carpets and curtains.’ -‘Food is good. Enjoy the outings. Satisfied in Wellburn.’ Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 6 Relatives and visitor comments included; - ‘ Always receive a very high standard of care.’ - ‘The staff are always hard working and very friendly.’ - ‘Made extremely welcome. All the staff have gone out of their way to make X feel at home.’ - ‘My questions have been answered promptly and honestly.’ - ‘Wellburn House is a well run home.’ - ‘The manager tries to accommodate.’ -‘I am extremely satisfied with all aspects. The home is extremely well managed and the staff are superb.’ - ‘This is a very caring, clean and happy home. The staff are 100 and much appreciated.’ - ‘I have been impressed by the efforts staff have made… to sort out any communication problems promptly and sensitively.’ -‘They are very open and Approachable and genuinely concerned at all times.’ -‘The staff do everything to keep my relative in great comfort.’ -‘Just gets better all the time. The staff never let standards decline.’ -‘Staff are all friendly, pleasant and efficient. My thanks to them all.’ - ‘This is one of the best homes we come to.’ The management are responsive to change and want to develop and improve the service. There is a good multi-disciplinary approach to care. The staff team is stable and have good relationships with the service users. Staffing levels were appropriate to meet the needs of the service users. What has improved since the last inspection? All the requirements made at the last inspection regarding medication, care plans and the premises have been addressed f0r the benefit of the service users. The refurbishment of the home continues to provide a good quality environment for the service users to enjoy. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 7 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. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 8 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 Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 9 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): 3 Service users needs are assessed before they are admitted to the home. EVIDENCE: Three care plans were examined and detailed assessments are in place. Staff have good relationships with service users and their families. Comprehensive assessment procedures ensure that the home does not offer places inappropriately. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Care plans are in place and staff have the information to meet service users needs. The health needs of residents are met and multi disciplinary working is taking place. The systems for the administration of medication protect service users. Service users are treated with respect and feel their privacy is protected. EVIDENCE: Three care plans were examined and found to be in good detail. The documentation regarding the care of residents is positive and the staff know the residents well. Personal preferences are now being recorded for such tasks as personal care. Residents said that they liked the staff and felt well looked after. Staff demonstrated that they know the resident’s needs and wishes and have good relationships. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 11 Care plans are evaluated monthly and reviewed. There is evidence of other professionals being involved. Risk assessments are in place and reviews are held 6 monthly. The requirements regarding the arrangements for the management of medication have been addressed. Service users views indicated that they felt that their privacy is respected. Service users are able to have their own telephone in their bedrooms. People are addressed by their preferred name. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 & 15 Service users are able to maintain relationships which are important to them. Service users are supported to maintain control over their lives. Service users receive nutritious meals but the detail on the menus does not reflect the practice of the home. EVIDENCE: 23 relative/visitor questionnaires said that they felt they could visit when they wished and were made welcome. Visitors during the inspection agreed. Service users are able to bring their own possessions with them from home. A nutritional audit tool (ref Rachael Chadwin Nutritionist, Newcastle General Hospital) was used to assess the homes 4- week menu. A copy of the audit was provided to the manager in July 2005. The assessment arrangements look at service users dietary requirements; preferences and care plans are devised where concerns are raised via nutritional screening tools. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 13 The menus are nutritious and service users said they enjoyed their meals. The lunchtime meal was pork in a spicy tomato sauce with pesto flavoured pasta or chipped potatoes and salad. The pudding was fruit with pouring cream or apricot sponge and custard. There is only one choice recorded on the menu at lunchtime. The Chef speaks to service users daily and will provide an alternative to the menu choice at lunchtime. However service users have commented that they do not know what the choice is. During lunch the inspector asked for the alternative to pork and was offered and provided with a delicious cheese omelette. One of the service users said if they had known there was an omelette they would have preferred that although they liked pork. Another comment was - ‘I would like to be told what’s on the menu beforehand in case there is an alternative if I don’t like it. - ‘ Meals could be more varied and more nutritious. Menus should be on display.’ -‘It (food) could be hotter when brought to the room.’ This comment was discussed with the manager. Appropriate food covers are used to transport food to bedrooms and a Bain- Marie is used in the dining room. The manager agreed to monitor. Types of in-between meal snacks, fruit and drinks are not recorded on the menus despite a wide choice available at any time. Service users can have anything for breakfast but this detail is not recorded on the menus. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Systems are in place to protect service users from abuse. EVIDENCE: Policies and procedures are in place which refer to good practice referring concerns to CSCI, and quality assurance arrangements monitor performance. Whistle blowing procedures and training to staff are in place. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users live in a home which is suitable for their needs. Current refurbishment and building works are not having a detrimental effect on the service users. EVIDENCE: The inspector saw the downstairs communal areas. The new lounge is spacious, homely and furnished to a high standard. During the visit a keep fit session was being held in the lounge and service users said they enjoyed it every week. The lounge has a bar and an opening party was recently held and everyone was invited. A new kitchen has been installed but was not inspected during this inspection. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. Service users are protected from potential harm as robust recruitment systems are in place. Service users are cared for by staff that are trained and competent. EVIDENCE: The home maintains the level of staffing in accordance with previous agreements with the local authority and this reflects the size and layout of the building and the needs of the residents currently living in the home. The current levels of staffing are a minimum of 4 care staff (and at times increases to 5) on duty during the day and 2 waking night staff. The staffing levels will be reviewed once the building works are completed and the registration increases to 35 service users. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 17 The registered manager is allocated 16 hours off the rota. The health and safety officer and entertainment officer are allocated 2 hours off the rota. Staff recruitment records were checked including Criminal Records Bureau records (CRB’s), Protection of Vulnerable Adults (POVA) checks, references, proof of identity and applications. New staff are provided with a comprehensive Induction programme. The General Social Care Council Code of Conduct for Employees should be provided to all staff. The copy included in the Induction pack is the Employers version. Staff are provided with mandatory training such as First Aid, Food handling, Moving and Handling and Fire Safety. Training programmes are in place and linked to staff appraisal and supervision. The home has over 50 of care staff with NVQ Level 2. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 35 Quality assurance systems are in place, which ensure that the service provided to service users is monitored and improved. Robust arrangements are in place to protect service users from financial abuse. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 19 EVIDENCE: Wellburn Care Homes Ltd has Quality Assurance systems in place. They have ISO9001/ Health mark Certification and work to the principles of Investors in People Award. Quality Management Reviews are periodically held. Internal and external audits are made which include Regulation 26 monthly visits and reports by the Company’s representative. The home is continually looking to improve the service provided to service users. Service users personal finances that are looked after by the home were checked. Amounts were correct, appropriate records maintained and there are external and internal audits in place. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 16 & schedule 4 Requirement The menus must be in sufficient detail – 1. Alternatives to the main course recorded and shared with service users. 2. Snacks must be on the menu and include fruit availability 3. Breakfast must be on menus. Timescale for action 31/12/05 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 OP29 Good Practice Recommendations The General Social Care Council Code of Conduct should be provided to all staff. Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wellburn House DS0000000623.V254060.R01.S.doc Version 5.0 Page 23 - 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. 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