Inspection on 20/07/05 for Wellcroft

This inspection was carried out on 20th July 2005.

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

The inspector 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 13/02/07

Wellcroft 13/02/06

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 SK8 4EY Lead Inspector Kathleen Mcall Unannounced 20 July 2005 09:30am 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. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wellcroft Address 75 Church Road, Gatley, Stockport, Cheshire SK8 4EY 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) 0161 428 5361 Borough Care Limited Mrs Margaret McNulty Care Home 38 Category(ies) of DE(E) - Dementia - over 65 - 38 registration, with number MD(E) - Mental Disorder - over 65 - 5 of places Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Wellcroft is a two-storey home, which provides specialist care for service users with mental health problems, it is currently registered for up to 38 residents. The registered manager is a Mrs Margaret McNulty. Wellcroft also provides short stay respite care breaks and day care for up to 3 persons per day. An activities co-ordinator is employed 15 hours per week, to provide activities each morning, Tuesday to Friday for both permanent and day care service users. Wellcroft is one of 12 care homes owned by Borough Care Limited. Accommodation comprises of both single bedrooms and seven shared double bedrooms. The home is suitable for wheelchair users and has a lift to assist service users to the first floor. The home is structured into three separate units and is staffed by its own team of carers. Each unit has kitchen and dining room facilities, bathroom with hoist and toilet facilities all in easy reach of service users bedrooms. The home is located at the far end of Gatley village. It is set in its own grounds that are well maintained. A large car park is available at the front and side of the building. Wellcroft is currently undergoing a major refurbishment programme, this will involve building seven en suite bedrooms onto the existing flat roof of Wellcroft and for all shared bedrooms to be made into single accommodation rooms. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit, which took place over the course of a day. The registered manager was not available at the time of the inspection. The deputy manager assisted the inspector throughout the inspection process. Care plans, assessment documentation, medication and their storage were examined. The inspector spoke with a number of residents in the home and had a discussion with two relatives who was visiting the home at the time of the inspection, and spoke with several members of staff. There are plans not to admit any new residents until the completion of the refurbishment programme in early 2006. What the service does well: Wellcroft offers comfortable accommodation that provides both flexible and stimulating care to residents. At the time of the inspection building work was well under way, which was being carried out in a planned and sensitive manner, without affecting the day-to-day routine of residents. Those areas of the home that residents had access to were well maintained and clean. The staff group at Wellcroft have a good understanding of all the residents care needs. Staff have a gentle and patient approach with residents and staff are 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. There is a full programme of activities that takes place throughout the week. An activities co-ordinator arranges activities four mornings per week and weekend staff are responsible for arranging weekend activities. The hairdresser visits the home weekly. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 6 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 F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4. Service users care needs were fully assessed before admission. The home met service users care needs. EVIDENCE: There had been no new admissions to the home since September 2004 due to the planned refurbishment programme. A number of files of service users who had been resident at the home for some time were examined. These files contained information, which confirmed it was the practice of the home that all service users were assessed prior to their admission to the home; no service users were admitted to the home without having had their care needs assessed. Assessments were obtained from social workers if they had been involved in the admission. Borough Care had its own assessment documentation called the “key-working together document”; this was completed for all new service users irrespective of their funding arrangements. Relatives with whom the inspector spoke were very appreciative of the efforts of the care staff in meeting their relatives health needs. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 9 The needs and preferences of service users were recognised and met by care staff. Care staff demonstrated a good understanding of all service users care needs. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10.. Service users health and personal care needs were identified and met. EVIDENCE: All service users had a care plan. Care plans seen were individualised to each service users care needs with information held in one accessible document. This information included risk assessments, moving and handling assessments, weight charts, 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 living there. GP’s, district nurses and community dieticians were regular visitors to the home. 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. The temperature of this refrigerator was not monitored and recorded on a daily basis. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 11 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 staffs approach towards service users was sensitive and caring. In addition the inspector observed that the service users looked physically well cared for, many had been to the hairdressers and all were dressed in summer clothing with suitable footwear. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15. Service users lived in a stimulating environment and were encouraged to exercise choice and control whenever possible. 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. At the time of the inspection a tea dance was taking place, with the majority of service users involved. This was a lively and stimulating event for service users and staff. The tea dance was organised by the activities co-ordinator along with the assistant activities co-ordinator, who was a retired member of staff. On other days the activities co-ordinator visits each unit and spends time with service users doing knitting, manicures and hand massages. A social evening was held on Saturday’s with singing and occasionally a chip shop supper. The activities co-ordinator told the inspector that most weekends the home tries to arrange an activity. Visitors were made welcome at the home and service users kept in touch with family and friends. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 13 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 F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 standard(s) 16 and 18. The home had a complaints policy and procedure. Not enough staff had undertaken appropriate training in adult protection. EVIDENCE: The home had a detailed complaints policy and procedure. Two complaints had been made to the home since the last inspection in February 2005. All complaints received at the home were recorded in a hardback book, which contained information relating to several service users. This information was not maintained in accordance with the Data Protection Act 1998. The home had a procedure for responding to allegations of abuse. A small number of staff had undertaken training in Adult Protection. Whilst a number of care staff had completed or were undertaking National Vocation Qualification training which looked at issues around adult protection and abusive care practices in residential care homes a large number of staff had not completed specific training in adult protection. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 standard(s) 19, 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. The home had 24 service users and had not taken any new admissions in the last nine months to accommodate the building work. At the time of the inspection the Edinburgh unit was not in operation and all service users were being accommodated on the York and Balmoral units. Building work was being carried out in a planned and sensitive manner, which took into account the needs of service users. Those 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. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 16 The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 17 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 and 29. The home was sufficiently staffed with a staff group that was trained to undertake their duties. The homes recruitment procedure ensured that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed to meet the needs of service users. A staff rota showing which staff was on duty and in what capacity was kept at the home. Staff appeared to have a positive relationship with the service users. Three new members of staff had commenced employment at the home since the last inspection; the registered manager had followed appropriate recruitment procedures with regard to newly appointed staff. The deputy manager informed the inspector that all new staff completed a period of induction at the commencement of their employment and existing staff confirmed that they had undertaken further training to assist them in their role as carers. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 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) 35, 36 and 38. Staff were supported and supervised in their work. Health and safety issues at the home were addressed. Records were not maintained in accordance with the Data Protection Act 1998. EVIDENCE: The home had a policy of not managing service users monies and did not act as appointee for any service users. All service users had a relative or a representative who dealt with their finances. Small amounts of cash were kept for individual service users for day-to-day expenses ie. hairdressing costs. Records of all transactions were kept along with the receipts. All service users had a secure facility in their bedrooms for personal items, although service users were encouraged to leave anything of great value with their relatives or friends. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 19 Staff confirmed that they received regular supervision and written evidence to support this was made available at the time of the inspection. Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. The home maintained records in respect of fire safety at the home. The home records information in respect of falls and accidents by service users, this information is stored in three places, two of which were not maintained in accordance with the Data Protection Act 1998. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 3 3 2 3 Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 21 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 OP 9 Regulation 13(2) Requirement The registered provider must ensure that the temperature of refrigerators used to store medication is monitored and recorded on a daily basis and that staff are aware of the action to be taken should the refrigerator temperature not remain within safe limits. The registered manager must ensure that all information stored in relation to complaints made by service users or their relatives is maintained in accordance with the Data Protection Act 1998 The registered manager must provide training in Adult Protection to all care staff employed at the home. Timescale for action 20th July 2005. 2. OP 16 12(4)(a) 20th October 2005. 3. OP 18 13(6) 20th October 2005. 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. Wellcroft Refer to Standard OP 37 Good Practice Recommendations The registered manager must ensure that all information F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 22 stored in relation to falls and accidents by service users is maintained in accordance with the Data Protection Act 1998. Wellcroft F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, Hertiage Wharf Portland Place Ashton-under-Lyne 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 F54 - F04 S8593 Wellcroft v238506 200705 Stage 4.doc Version 1.40 Page 24 - 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!