Inspection on 13/02/06 for Wellcroft

This inspection was carried out on 13th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellcroft 05/02/09

Wellcroft 13/02/07

Wellcroft 20/07/05

Wellcroft 22/02/05

Wellcroft 27/09/04

Wellcroft 15/03/04

Wellcroft 20/01/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOMES FOR OLDER PEOPLE Wellcroft 75 Church Road Gatley Stockport Cheshire SK8 4EY Lead Inspector Kathleen Mcall Announced Inspection 13th February 2006 10:30 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 Wellcroft DS0000008593.V274961.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. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wellcroft Address 75 Church Road Gatley Stockport Cheshire SK8 4EY 0161-428 5361 0161 428 1216 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) Borough Care Limited Mrs. Margaret McNulty Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5) Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Wellcroft is a two-storey home, which provides specialist care for residents with mental health problems; it is currently registered for up to 38 residents. The home provides permanent residential care services and day care services. Wellcroft is currently undergoing a major refurbishment programme, this will involve building seven en suite bedrooms onto the existing flat roof of Wellcroft and all shared bedrooms will become single accommodation rooms. It is anticipated that the refurbishment will be completed by April 2006. Wellcroft is one of 12 homes owned by Borough Care Limited. The registered manager is a Mrs Margaret McNulty. The home is suitable for wheelchair users and has a lift to assist residents to the first floor. It is structured into three separate units each staffed by its own team of carers. The home employs an activities co-ordinator who provides activities most morning, to both permanent and day care service users. The home is located at the far end of Gatley village. It is set in its own grounds. A large car park is available at the front and side of the building. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over the course of a day. The registered manager and the deputy manager assisted the inspector throughout the inspection process. Care plans, assessment documentation, medication and its storage were examined. The inspector spoke with a number of staff that were on duty at the time of the inspection. The inspector spent time with a number of residents. The majority of residents at Wellcroft were unable to comment in detail on the quality of care they received due to their levels of dementia. Two relatives comment cards were returned. Both cards indicated that they were satisfied with the overall care provided and neither had made a complaint. Both cards indicated that they were made welcome at the home at any time and that they were kept informed of important matters concerning their relatives. Comments from relatives included, ‘the staff have always seemed to treat the residents kindly and with consideration’. Another said ‘I think Wellcroft provides a very good standard of care to its residents and the staff always seem to be very competent’. What the service does well: At the time of the inspection the home was undergoing a refurbishment programme that included building seven en-suite bedrooms on to the flat roof area of the home. In addition to this work, all other bedrooms had been redesigned or redecorated. New lounge areas and bathroom areas had also been provided. Wellcroft continued to offer comfortable accommodation for the residents. At the time of the inspection building work was being carried out in a planned and sensitive manner with the aim of minimal disruption for residents. Those areas of the home that residents had access to were well maintained and clean. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 6 The home has a structured programme of activities on offer and residents have the choice of joining in or choosing to spend their time as they please, which may include using one of several lounges situated around the home. Activities take place on each unit most weekdays with a smaller numbers of residents thus enabling the activities co-ordinator to spend more one to one time with individual residents. Larger group activities also take place each week, a tea dance is held every Wednesday and a social evening is held on Saturday evenings. The atmosphere of the home is relaxed and friendly. The staff group at Wellcroft appear to have a good understanding of the residents’ care needs and demonstrated a gentle and patient approach with residents. Staff were able to include within their working day time to sit and talk to residents. The staff group at Wellcroft is a trained and well-supervised group. Assessment and care planning arrangements were good. 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. Wellcroft DS0000008593.V274961.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 Wellcroft DS0000008593.V274961.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 and 3. Service users’ care needs were fully assessed before admission. EVIDENCE: Service users admitted to the home had a written contract which detailed the terms and conditions of their stay. Several new service users had been admitted to the home since the last inspection. As part of the inspection, a selection of service user files were examined. These contained a sufficient amount of assessment information in respect of each service user. It was the practice of the home that service users were assessed prior to their admission. Assessments were obtained from social workers and health professionals if they had been involved in the admission and no service users were admitted to the home without their care needs having been assessed. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 9 Borough Care had its own assessment documentation called the “key-working together document”; which was completed in respect of all new service users admitted to the home. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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 and 10. Service users’ health and personal care needs were identified through care planning and met by care staff. EVIDENCE: All service users had a care plan. Service users’ care plans were stored in their bedrooms. Care plans seen were individualised to each service user’s care needs with information held in one accessible document. This information included risk assessments, moving and handling assessments, weight charts, oral hygiene programme, daily records and a review sheet. Care plans were reviewed on a monthly basis and any changes needed were included. Care plans were usually drawn up with a service users relative or a professional who may have been involved in their admission to the home. Wellcroft had specialist equipment in place to meet the needs of service users. The home was undergoing a refurbishment programme, a part of which included installation of several assisted bathrooms and a walk-in shower. GP’s, district nurses and community dieticians were regular visitors to the home. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 11 Medication practice at the home was assessed in response to requirements made by a pharmacist inspector following the previous inspection. This included records of administered medication, the labelling of medication received into the home, the practice and use of ‘covert’ administration of medications, the storage of medication and clarity regarding ‘as required’ medication. Medication was provided in the Vena link system, this was stored appropriately and medication records were accurately maintained. The home had a secure dedicated refrigerator for the storage of medication requiring refrigeration. Since the last inspection the temperature of the refrigerator was monitored and recorded on a daily basis and arrangements around the practice of ‘covert’ administration had improved. The labelling of medication received into the home remained an issue for concern. The majority of service users resident at Wellcroft were unable to comment in detail on the quality of care they received due to their levels of dementia. Consequently, the inspector spent time observing the practices of staff and the daily routine of the home and observed that staff’s approach towards service users was sensitive and caring. In addition, the inspector observed that the service users looked physically well cared for. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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): 12, 13, 14 and 15. The day-to-day routine of the home, including mealtime arrangements, was relaxed and informal and met service users’ needs. EVIDENCE: Wellcroft offered a flexible routine to service users. Staff encouraged service users to make choices as to how they spent their time, whether they wished to join in activities or not, what they ate and what clothes they chose to wear. The home employed an activities coordinator to provide activities up to five days per week for approximately three hours per day. Activities were held in the morning before lunch, the co-ordinator and the registered manager felt this time suited the needs of the service users, as opposed to having activities in the afternoon when visitors called. The home was structured into two units. The activities co-ordinator divided her time between the units in one hour sessions; activities included armchair exercises, knitting classes, manicures and arts and crafts. Once per week activities were held in the downstairs lounge and all service users had the choice of attending, these activities included a weekly tea dance. Periodically, concerts were held and a social evening was held every Saturday evening. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 13 At the time of the inspection two church lay visitors were in the home providing a service of prayer and hymns for service users. Visitors were made welcome at the home and service users kept in touch with family and friends. Meals were served at regular intervals and were usually taken in the dining room areas. A hot meal option was offered at both lunchtime and teatime meals with the exception of Sunday teatime when a cold buffet tea was offered. Staff were on hand to help service users with meals and meal times were unhurried. A number of service users told the inspector that they had enjoyed their lunch. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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 Staff had undertaken appropriate training in adult protection. EVIDENCE: The home had a procedure for responding to allegations of abuse. It was a requirement at the last inspection that all care staff completed training in the Protection of Vulnerable Adults. At the time of this inspection all care staff, with the exception of six members of staff, had completed such training. Further training on the Protection of Vulnerable Adults was scheduled to take place on the 6th April 2006 when the remaining six care staff were expected to attend. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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, 21, 24 and 26. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: At the time of the inspection work on the refurbishment of Wellcroft was well underway. Building work was being carried out in a planned and sensitive manner, which took into account the needs of service users. Areas of the home that service users had access to were well maintained and provided comfortable accommodation. Service users had access to toilets and bathroom areas. A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. The home met fire safety regulations. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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, 28 and 29. The home was sufficiently staffed with a staff group that was trained to undertake their duties, and recruitment procedure ensured that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed with a staff that was trained to meet the assessed needs of service users. A staff rota showing, which staff were on duty and in what capacity, was kept at the home. Since the last inspection five new members of staff had commenced employment at the home; the registered manager had followed appropriate recruitment procedures. Out of a total staff group of 21 care staff, 17 staff held an NVQ level 2 qualification. Care staff on duty at the time of the inspection confirmed that they had undertaken further training to assist them in their role as carers including POVA training, Dementia Care, medication and moving and handling. Wellcroft DS0000008593.V274961.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): 31, 36 and 38. The home was well managed for service users and care staff were appropriately supervised. The health and safety of staff and service users was safeguarded. EVIDENCE: The registered manager, Mrs Margaret McNulty, has over twenty years’ experience in working in the residential care sector, she has been the manager at Wellcroft for 15 years. The registered manager had completed an NVQ Level 4 in Management and Care and holds the Registered Manager’s Award. Staff received regular supervision to support them in their work and records of such meetings were made available at the time of the inspection. Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 18 The home complied with the requirements of the fire authority and maintained records in respect of fire safety at the home. Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. The home recorded information in respect of falls and accidents by service users. This information was regularly reviewed and monitored to see if patterns were evident and measures to address emerging patterns were put in place. Wellcroft DS0000008593.V274961.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X 3 Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 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 OP9 Regulation 13 Requirement Timescale for action 13/03/06 2. OP9 13 The registered person must ensure that monitored dosage systems received by the home are appropriately labelled with a description of the medication contained. (Timescale of 21/09/05 not met) The registered person must liaise 13/03/06 with the supplying pharmacist to ensure that all medication received by the home is labelled on both the inner container and the outer box. 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 Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Wellcroft DS0000008593.V274961.R01.S.doc Version 5.1 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!