Inspection on 13/02/07 for Wellcroft

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wellcroft 05/02/09

Wellcroft 13/02/06

Wellcroft 20/07/05

Wellcroft 22/02/05

Wellcroft 27/09/04

Wellcroft 15/03/04

Wellcroft 20/01/04

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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 Michelle Haller Unannounced Inspection 13th February 2007 09:30 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.V330408.R01.S.doc Version 5.2 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.V330408.R01.S.doc Version 5.2 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 39 Category(ies) of Dementia - over 65 years of age (39), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5) Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users to include: *up to 39 service users in the category of DE(E) (Dementia over 65 years of age). *up to 5 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). The ratios of care staff to service users must be determined according to the assessed needs of residents and in accordance with guidance issued by the Department of Health. 19th January 2006 2. Date of last inspection 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 39 residents. The home provides permanent residential care services and day care services. Wellcroft has recently undergone a major refurbishment programme; this included making nine en-suite bathrooms and all shared bedrooms have been made into single accommodation rooms. 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 mornings, 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. The home charges £390 per week and an additional £4- £6 is requested to pay towards activities and entertainment. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which included an unannounced site visit to the home, was undertaken on 13th February 2007 over a period of seven hours. Two hours were spent observing the care being given to a small group of people. The care of three people was looked at in depth, when comparison with the observations were made with the home’s records and the knowledge of the care staff. Three service users and relatives were interviewed. Two members of staff were interviewed and in-depth discussions with the manager and deputy manager also took place. Examination of seven care files and all records and reports pertaining to these service users was undertaken. Other documents concerned with the running of the home were also examined. A tour of the private and communal areas of the home was also completed and during the course of the day the interactions between staff, service users and their relatives was observed. What the service does well: The home provides safe, homely, clean and well-maintained accommodation. Staff are welcoming and will listen to service users and their relatives. The home provides nutritious food and provides activities that prevent boredom. The manager and staff are approachable, well trained and ensure that service users receive a high standard of health and personal care. The home’s recruitment and selection process is good and makes sure that only staff who are suitable to work with older people are recruited. The home safeguards the health and safety of service users by making sure that guidelines and policies are followed. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 6 Comments from service users included: ‘‘I am happy - they do a good job’; and ‘It’s ideal – can’t find fault - I like it very much.’ And a relative stated - ‘I would say they are very well looked after here.’ 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. The summary of this inspection report can be made available in other formats on request. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 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.V330408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 does not apply) Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home makes sure that it understands the needs of service users prior to providing a service. EVIDENCE: A cross-section of service users’ care files was examined, and included the most recent admission and a service user requiring intensive support. The majority of care files contained a variety of assessments that included health care, risk of falls and moving and handling assessments. Information about the most recent admission was sparse and was yet to be completed. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 9 The majority of service users are affected by dementia, however the initial assessments did not always include a psychological or behavioural profile about how the dementia was affecting individuals. Social history is assessed, however the information, in most cases, lacked detail. Quality in this area could be improved if the home made sure that the assessments included the psychological and behavioural needs of service users, and also demonstrate that every effort is made to gather a social history and past interests for all service users. The home also needs to make sure that assessments are in place for all new admissions before they move into the home. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Wellcroft makes sure that health and personal care delivered is based on individual needs and which respects the individual right to privacy and dignity. EVIDENCE: Detailed care plans identifying the assessed needs of service users were in place. These were readily accessible and kept in the service users’ bedrooms. Records, reports and other correspondence confirmed that service users had access to all necessary routine and specialist health care, including general practitioners, dentist, district nurses, mental health nurses, dieticians, optician and specialist consultants through attending outpatients hospital appointments. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 11 Specialist equipment, such as pressure area care beds, is provided and staff follow the instructions provided by district nurses and others involved in planning care. Care plans are reviewed and the care provided updated each month or more frequently in response to the needs of service users. Medication is received into the home and administered in a manner that safeguards service users and maintains their independence. The medication policy was examined and the guidance promoted safe administration, storage and recording. The medication trolley and fridge were checked and all medication was fully labelled and stored at the correct temperature. The medication round was observed and it was noted that staff appeared knowledgeable about each medication, and explained the reason for the medication to the service users as it was administered. It appeared throughout the day that service users’ dignity was fully respected and maintained. Service users appeared well groomed, neat and tidy. Many were wearing prescription glasses and had been supported in wearing hearing aids. Daily records are written in a respectful manner and demonstrated that staff develop a rapport with service users. During the inspection a small number of residents were observed for two hours in the morning. Most of the residents appeared to be in a generally positive state of being for large parts of the time, starting up small conversations with staff or other residents and taking an interest in their surroundings and the people around them. Interaction between staff and residents was generally positive, with staff showing care and concern for residents. Residents appeared to like the staff and were relaxed and comfortable. Staff should take care to address the residents by name instead of using general terms such as “love”, in order to emphasise their individuality and preserve their dignity and respect. Comments from service users included: ‘‘I am happy - they do a good job’; and ‘It’s ideal – can’t find fault - I like it very much.’ And a relative stated: ‘I would say they are very well looked after here.’ Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Wellcroft tries to ensure that social, cultural and recreational activities meet the residents’ expectations and that healthy well-balanced meals which the residence enjoy are provided. EVIDENCE: The organisation employs an activities co-ordinator who plans a variety of activities three days a week, these include arts and crafts, manicure, themed days and outings to tourist attractions. A record is maintained of the activities individual service users have enjoyed. Discussion with the activities coordinator identified that although she had some good ideas, she had not received specific training concerned with developing an activities programme for people with dementia. The manager was able to show, however, that this training was to be provided in the near future. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 13 The activities recorded and daily records indicated that most recreational activities were provided in groups with little opportunity to pursue individual interests. This could be addressed if the home gathered a more detailed social history from service users, family, friends and social workers. Discussion with the manager and comments from relatives and friends confirmed that visiting in the home is open and relatives and friends are made welcome. One visitor observed that “I can visit when I like and they keep very close contact with the family.” Service users and relatives are encouraged to personalise rooms with items such as furniture, pictures and ornaments. This area could be improved if people without the involvement of family and friends were also supported in making their rooms more homely. The meals and snacks provided by the home are wholesome and meet the taste of service users. The cook has achieved NVQ level 2 in catering. The lunchtime menu on the day of inspection was sausages and onion gravy served with mashed potatoes and mixed vegetables; this was followed by home made sponge pudding and custard. The teatime meal was macaroni cheese and ham with salad. Hot and cold drinks were also served throughout the day. The menu is on a four week rota and meals included a choice of traditional British food such as roasted meats, pork chops, savoury pies, bubble and squeak, cauliflower cheese and also less traditional meals such as sweet and sour pork and tuna bakes. Meals are served in pleasant surroundings and service users are provided with modified cups and eating utensils so that they can maintain their independence. Those who require extra support at meal times are treated with dignity and patience. All service users are weighed monthly and the food and drink intake of the frailest service users is recorded. A record is also kept of each meal that service users have chosen. Comments made about the food in the home included “When I’ve been here at meal times it’s been very good - there seems to be no restrictions on quantity and everything is set out nicely” and “If the main choice is something they don’t want, the cook always provides an alternative.” Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home ensures that service users are protected by robust and effective complaints and adult protection policies. EVIDENCE: Information provided by the detailed complaints log demonstrated that complaints were taken seriously and investigated fairly and within an acceptable period of time and in keeping with the home’s policy. The home’s complaints procedure is on display and readily available to all who visit the home. Relatives who were interviewed stated that the staff and management team were approachable and any issues or concerns were dealt with quickly. The manager stated that there had not been any allegations of abuse in the home. The adult protection and whistle blowing policy was read through and identified the behaviours and omissions that staff should report. This policy was last updated in 2005 and the manager stated that this policy was in line with Stockport Council’s adult protection policy. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 15 When questioned staff were able to respond correctly in relation to the steps they would take if they had any concerns with regards to abuse. Records confirmed that the all staff had received adult protection training within the past two years. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Wellcroft provides an environment that enables residents to live in a safe wellmaintained and comfortable environment, which encourages independence. EVIDENCE: Since the last inspection the home has undergone extensive refurbishment and now provides all single accommodation and nine bedrooms with en-suite. A tour of the entire building and gardens was undertaken. The home was clean and pleasantly decorated. with it’s own sitting and dining areas. There are three units, each Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 17 The bathrooms, toilets and other facilities are adapted with easy use taps, raised seats, hoists and grab rails. Maintenance records confirmed that all moving and handling equipment was serviced and maintained by people qualified to do the work. Service users were observed walking around the home independently or using the equipment provided. The laundry area was clean, neat and dry and the washing machine has the required sluice facility and hot water temperature. The kitchen was deep cleaned on the day of inspection and the home is participating in the ‘Safer Food Better Business’ initiative run by the local Health and Safety department. All areas of the home were clean, comfortable, homely and pleasant to use. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Wellcroft provides staff who are well trained and in sufficient numbers to meet the needs of those living in the home. EVIDENCE: On the day of inspection there were 38 service users at Wellcroft and staff on duty numbered 14, including managers and housekeeping staff. At night there are two wake and watch members of staff and one sleep-in. During the day it was observed that staff had enough time to sit and talk to service users and organise games such as dominoes. Staff and relatives felt that there were enough staff on duty to prevent service users from being rushed. Staff records confirmed that all had been employed using a robust recruitment and selection process. Application forms, two references and Criminal Record Bureau checks were in place. In addition, there was further proof that identity and health declaration forms had been signed. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 19 Training is good and new staff had received induction training in line with recommendations from the Skills for Care training organisation. The training calendar and records of attendance confirmed that established staff had also received appropriate training in the past 12 to 18 months. Training had included: Yesterday, Today and Tomorrow which is a course about working with those experiencing dementia; pressure area care; an introduction about hearing loss; basic and advanced first aid; loss, grief and bereavement; food safety; falls prevention, infection control, moving and handling, basic sign language; fire safety and managing conflict. This training is provided through the Borough Care organisation of which Wellcroft is a part. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The management arrangements in place ensure the home is well run and in a manner which services users and relatives feel they can contribute to. EVIDENCE: The registered manager has attained the National Vocational Qualification level 4 in management award. The running of the home appears efficient; supervision records indicate that staff are well managed. Relatives and staff stated that the managers were approachable. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 21 The home conducts a yearly review; this document now has a questionnaire on the back and the information will be analysed. The organisation is making plans to involve relatives and the social workers of service users with severe memory loss. The home has attained the Investors in People award. Service users’ money is fully accounted for and kept secure. All steps have been taken to safeguard the health and safety of service users. The fire logs were checked and these confirmed that all lighting and fire exits are checked weekly and fire drills take place monthly. Accident reports are maintained and it was noted that the manner in which accidents concerning service users should be changed to meet the requirements concerning confidentiality as a number of accidents are recorded on a single page. Borough Care carries out an audit and produces a report analysing the reasons for falls in the home. Maintenance records confirmed that electrical and gas safety checks were conducted in accordance with the relevant regulations. Health and safety training including first aid, infection control and food hygiene is provided to all staff. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 22 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 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP3 OP10 Good Practice Recommendations The registered manager should include an assessment of psychological, emotional and social history needs for all service users. The registered person should make sure that staff take care to address the residents by name instead of using general terms such as “love”, in order to emphasise their individuality and preserve their dignity and respect. Wellcroft DS0000008593.V330408.R01.S.doc Version 5.2 Page 24 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V330408.R01.S.doc Version 5.2 Page 25 - 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. 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