CARE HOMES FOR OLDER PEOPLE
Wellburn House Main Road Ovingham Northumberland NE42 6DE Lead Inspector
Deborah Haugh Unannounced 04 July 2005 09:30 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. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Wellburn House Address Main Road Ovingham Northumberland NE42 6DE 01661 834522 01661 839420 N/A Wellburn Care Homes Limited 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) Mrs M Armstrong CRH 33 Category(ies) of A - Alcohol dependence past/present (1) registration, with number OP - Old Age (32) of places Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: DE - Dementia (6) Date of last inspection 14/12/04 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 B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 4/7/05 at 10am and lasted until 4pm. At the time of this inspection the Registered Manager Mrs Margaret Armstrong was on duty. 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 and staffing levels were appropriate to meet the needs of the service users. Time was spent looking around the home to check the cleanliness, maintenance and decoration. Service users shared their views about the home. Time was also spent observing the contact between service users and staff. Three Care Plans for service users care were examined. The home’s Fire Log and maintenance systems were checked. Arrangements for the administration and management of medication were audited. What the service does well:
The service users said that they liked the home and in particular their relationship with staff, the food and activities. ‘Good food, clean home.’ ‘I think I’ll settle here.’ ‘I like my room.’ ‘I have a special person, we understand each other.’ Visitors were made welcome and obviously know the manager and her team well. Since December 2004, 7 compliments were received from relatives. A range of activities are available such as keep fit, yoga, art group and bridge. Service users can have newspapers, friends over for drinks or meals, garden, cook and help in the home. Service users join in the community events such as a recent Rose Festival and Celebration of Music. Local schools visit and a BBQ is planned for 15/7/05. The standard of accommodation meets the needs of the service users and is being improved so that there are more bedrooms with ensuites, usable space and more communal space. The new kitchen, laundry and hairdressing room
Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 6 provide better facilities and demonstrates the commitment of Wellburn Care Homes Ltd to improve standards for the benefit of service users. The Fire Safety checks, drills and instructions to staff by the competent person are comprehensive. Service users needs are assessed by the home and care plans are in place to meet them. Relationships between service users and staff are good. Staff described the needs and wishes of the service users they care for. What has improved since the last inspection? 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 B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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 Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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) 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 and management explained their approaches to the care of service users. Staff have good relationships with service users and their families. Comprehensive assessment procedures ensure that the home does not offer places inappropriately. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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) 7,8,9 Care plans are in place and staff have the information to meet service users needs. However care plans do not reflect the personal preferences of service users regarding personal care. Staff demonstrated that they know the resident’s needs and wishes and have good relationships. The health needs of residents are met and multi disciplinary working is taking place. The systems for the administration of medication require improvements. EVIDENCE: Three care plans were examined and residents and staff spoke about their needs. The documentation regarding the care of residents is positive and the staff know the residents well. Personal preferences should be recorded for such tasks as personal care. Residents said that they liked the staff and felt well looked after. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 10 Care plans are evaluated monthly and reviewed. There is evidence of other professionals being involved. A risk assessment must be completed for one bedroom with consultation with the service user. An audit of the medication arrangements was undertaken in the presence of the manager and some areas require addressing. (see Requirements) Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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 standard(s) 12 & 15 Service users have access to a variety of activities. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices as well as special dietary needs. EVIDENCE: A social activities programme is displayed. Service users gave positive comments on being able to participate in activities and extensive social occasions. These ranged from a weekly art group, yoga, keep-fit and bridge club. Service users join in the community events such as a recent Rose Festival and Celebration of Music. Local schools visit and a BBQ is planned for 15/7/05. The cook demonstrated his knowledge regarding nutrition for older people and service users spoke positively about the food. Lunch was unhurried and service users are able to have alternatives to the menu at anytime. Wellburn Care Homes Ltd now have a Nutritionist to develop the menus of the residents. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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 The home has a satisfactory complaints system in place. EVIDENCE: No complaints have been made since the last inspection in December 2004. Service users spoke of their good relationships with staff and the manager. Any concerns are dealt with immediately. Seven compliments were received from relatives since December 2004. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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) 19,21,22,24-26 The standard of the environment within this home is good providing service users with an attractive, safe, clean and homely place to live. Current refurbishment and building works are not having a detrimental effect on the service users. EVIDENCE: A tour of the home was completed and the home was clean, well maintained and decorated. Service users said that they like their home and feel comfortable in their bedrooms. The Manager and her team ensure that the current building works has minimal disruption to service users during this period. The location and layout of the home is being refurbished and improvements to the kitchen, laundry, hairdressing and bedrooms are already being valued. Adequate numbers of bathrooms and wc’s are provided for the service users living in the home. However more ensuites are being provided. The ground
Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 14 floor bathroom will be upgraded and a new bathroom will be created during the refurbishment. Bedrooms are spacious, homely and personalised by the service users, relatives or staff. One carpet must be replaced as it is stained despite cleaning. One bedroom must also be risk assessed in consultation with the service user due to storage safety concerns. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 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 Staffing numbers are appropriate to the assessed needs of the residents, size and layout and purpose of the home at all times. 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 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 B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 16 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) 38 The health and safety checks are good and the safety of service users and staff are protected. EVIDENCE: The Fire Log is maintained and staff receive comprehensive instruction and drills by the competent person. A Fire Risk Assessment is in place but needs to be dated. Maintenance checks are in place. These include Control of Substances Hazardous to Health (COSHH), Risk assessments, hot water temperature and Legionella checks. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 17 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 x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 2 x 3 3 x 2 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 18 no Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement Handwritten entries on Medication Adminstration Record (MAR) sheets must be signed and countersigned. Dosage changes must be signed. Provide a key guide for abbreviations. Obtain an up to date BNF. Medication keys must be separate from other keys. The stained carpet in room 1A must be replaced within agreed timescale. A risk assessment must be completed for the identified bedroom with the service user Care plans must reflect service users preferences for example personal care). Timescale for action 31/7/05 2. 3. 4. 19 & 24 14 7 23 13(4) 15 31/7/05 31/7/05 31/8/05 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 38 Good Practice Recommendations Enter a date on the Fire Risk Assessment. Wellburn House B53-B03 S623 Wellburn House V231616 040705 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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
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