Inspection on 20/09/06 for Wellesley House Nursing Home

This inspection was carried out on 20th September 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 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

Wellesley House Nursing Home 09/02/06

Wellesley House Nursing Home 07/06/05

Wellesley House Nursing Home 04/02/05

Wellesley House Nursing Home 17/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Wellesley House Nursing Home 186 Penn Road Penn Wolverhampton West Midlands WV3 OEN Lead Inspector Joy Hoelzel Key Unannounced Inspection 20th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wellesley House Nursing Home DS0000017200.V297460.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. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellesley House Nursing Home Address 186 Penn Road Penn Wolverhampton West Midlands WV3 OEN 01902 342195 01902 342195 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) Mr Stephen Cadman Mrs Christine Cadman Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (33), Terminally ill (3) of places Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories (except 3 only terminally ill) Date of last inspection 9th February 2006 Brief Description of the Service: Wellesley House is a registered care home providing accommodation, personal and nursing care for up to thirty three older people. Weekly fees range from £327.00 - £460.00. Situated just over a mile from the centre of Wolverhampton, Wellesley House is a converted two storey building, dating from around 1845 and standing in its own grounds. The home is on the main bus route, with easy access to local shops and pubs. The 33 beds are contained in a mix of single and double rooms. The home is currently undergoing building work to extend the property and to alter the existing building to increase the number of single bedrooms. The home is well managed and staff work hard to maintain high standards and a pleasant atmosphere. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over five hours on Wednesday 20th September 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty three of the thirty eight National Minimum Standards for Older People were inspected. Twenty two people are currently living at the home; and throughout the time of the inspection were observed to be accessing all areas of the home. A first level nurse was on the premises and in charge of the building and was supported by six care staff with additional domestic and catering staff. The owner was at the home during the inspection. Three case files were selected for case tracking, relevant documents were inspected, discussions were held with service users, visitors and members of staff. Observation was made of the various daily activities and a tour of the premises was conducted. What the service does well: What has improved since the last inspection? Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 6 The two requirements made following the last inspection in February 2006 have been complied with; regular checks have been maintained to ensure that all bedrails in use are safe and fit for the purpose. 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. Wellesley House Nursing Home DS0000017200.V297460.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 Wellesley House Nursing Home DS0000017200.V297460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Significant time and effort is spent making admissions to the home personal and well managed. Prospective service users and their families are treated with dignity, respect and understanding for the life changing decisions they need to make. EVIDENCE: A full assessment of a persons care needs is carried out by a member of staff and received from the appropriate healthcare agencies, prior to offering a placement at the home. Visitors confirmed that they visited the home with their relative prior to making the decision to move in. The service user commented that as soon as he arrived at the home he realised that he had made the right decision to move into the home. The case file of the person most recently admitted to the home contained details of the care needs and was supported by information in a transfer form from a previous placement. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 9 The home does not offer an intermediate care service. Wellesley House Nursing Home DS0000017200.V297460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place, which provides staff with the information they require to meet service users needs EVIDENCE: Three case files were selected for inspection, one being of the person most recently admitted to the home, the others had been at the home for a period of time. Each service user has a plan of care initially based on the pre admission assessments and formulated at the point of admission. The care plan, risk assessments and monitoring tools are reviewed at least monthly or as a change in need is identified. Where ever possible the service user and/or representative is involved in the process but it acknowledged that at times some people do not wish to partake. The assessment of risk for moving and handling, nutrition and for the prevention of developing pressure areas are linked with a detailed plan of care. A clinical record contains information of the visiting healthcare professionals including GP visits. The person in charge confirmed that continence and tissue viability nurses are contacted when necessary. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 11 Any changes or alterations made to the prescribed medication regimen is recorded in the care plan and cross referenced with the Medication Administration Record. The home operates a twenty eight day medication administration regimen using blister packs with the additional use of bottles and boxes. The lunchtime medication round was observed with the first level nurse offering the medication and assisting in an appropriate manner. The Medication Administration Record (MAR) charts were completed at the time of the administration. The fridge for the cold storage of medication is kept locked; the temperature is taken daily and recorded. Internal and external preparations are stored in separate locked cupboards when not in use. During the tour of the premises tubs of external creams and lotions were in use, the date of opening had not been placed on the container, it was not possible to establish whether the recommended shelf life had expired. The care staff were observed to be assisting service users with personal care discreetly and in a manner which promotes service users’ dignity. Two visitors stated ‘ all the staff treat my relative with respect and courtesy’. Lots of chatter, conversations and interactions were observed between the service users, staff and visitors during the time of the inspection. All appeared to be very well at ease with each other. Wellesley House Nursing Home DS0000017200.V297460.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The daily living and social activities arranged for service users takes into account the differing expectations, preferences, lifestyle and capacities of each individual. EVIDENCE: The owner of the home stated that activities continue to be arranged on a weekly and monthly basis, and commented that not many people wish to go out of the home as they are too frail. Visitors also stated that their relatives are content with watching the TV, listening to music or just watching the ‘world go by’. One service user stated that he enjoyed going to his room in the afternoon and particularly liked to watch the sport. Many people were at the home visiting friends and family, and stated that they are always offered a warm welcome when visiting. During the tour of the premises many of the bedrooms were individualised with personal belongings. Staff were observed to be offering choices to service users throughout the day, the choices and options very much dependent on the capacity of the individual. The inspector was invited to join service users with the midday meal, the dining room was well prepared in advance, with the meal being presented in Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 13 an exemplary manner. Staff were observed to be serving and assisting in a relaxed, unhurried and discreet manner. Wellesley House Nursing Home DS0000017200.V297460.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and robust procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has its own complaints/concerns procedures, a copy of which is displayed at the entrance of the home. Visitors stated that if they had any concerns whatsoever they would not hesitate to see a member of staff and felt confident that their concern would be taken seriously. The owner of the home stated that one complaint had been received from a service user recently. This was thoroughly investigated, with a solution to the problem being offered. No complaints have been made either to the home or Commission for Social Care Inspection since the inspection in February 2006. The policies and procedures for adult protection have recently been reviewed by the home and a video has been purchased for further training for staff in this area. External training has also been accessed. Staff demonstrated a good knowledge of the procedures for dealing with service users personal monies kept at the home for safekeeping. All transactions are recorded with signatures and receipts being obtained and kept. A monthly audit is carried out to check the accuracy of the transactions. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 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): OP 19,26 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable place in which to live, the refurbishment and improvements will further enhance the environment for the people living at the home. EVIDENCE: The home is currently undergoing extensive alterations, refurbishment and redecoration. The owner explained the unexpected difficulties that have arisen during the building works causing a delay in the completion timescales but confirmed that disruption for the service users is being kept to a minimum. Visitors also stated that they and their relatives are kept fully informed of the building works and that it ‘hasn’t caused too much trouble’. One service user spoke of the newly refurbished and redecorated room that has been offered to her and was looking forward to the time when she could move in. The owner confirmed that the bedrails are regularly checked for the suitability and safe fitting. The case files contain a risk assessment for the use of bedrails and in one case the decision and reasoning for their non-use. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 16 Observations during the tour of the premises and discussions with safe confirm that systems are in place for the effective control of infection. The domestic staff should be commended for maintaining the home at a satisfactory level of cleanliness whilst the building work is in progress. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 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 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): OP 27,28,29,30 Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. There is an established staff group working positively and enthusiastically to provide service users with a quality of life that meets their individual requirements and aspirations. EVIDENCE: Staffing levels are maintained at a satisfactory level to ensure the needs of all the people living at the home are fully met. At the time of the inspection a first level nurse was in charge of the premises supported by six care staff and additional ancillary staff. The owner and administration personnel were also at the home. Duty rotas are maintained and evidence that this compliment of staff continues for the evening period, reducing to one first level nurse and two care staff for the night. Service users and visitors all commented positively on the attitudes, skills and expertise of all levels of staff. On observation, all service users looked extremely well groomed and well nourished it was obvious that all staff work very hard to maintain high levels of personal care. Three staff personnel files were selected for inspection, all the necessary identity checks have been carried out with records kept. Training opportunities continue in the core and specialist topic areas for all staff. Certificates and records of achievement are retained in the personnel files. Members of staff stated that they enjoyed working towards the National Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 18 Vocational Qualification accreditation in care and would like this level of training to continue. The administrator arranges the training courses and ensures that each staff member has a training schedule. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 19 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): OP 31,33,35,38 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. There are very clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the service users benefit. EVIDENCE: Since the last inspection in February 2006 the registered manager has taken retirement. A first level nurse has been recruited for the position of manager and is currently working at the home; the formal application is presently being processed. The owner stated that due to the major refurbishment of the premises the monitoring of the quality of the service has been deferred, but stated that plans have been made to reintroduce the systems and procedures during the year. Staff and service users meetings have continued on a monthly basis, Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 20 with the owner stating that daily informal chats with the service users, relatives and staff offer an indication of how the home is running. Staff demonstrated a good knowledge of the procedures for dealing with service users personal monies kept at the home for safekeeping. All transactions are recorded with signatures and receipts being obtained and kept. A monthly audit is carried out to check the accuracy of the transactions. Documentary evidence is available for promoting and protecting the health, safety and welfare of service users, staff and visitors. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 21 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 3 Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 22 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 Refer to Standard OP9 Good Practice Recommendations The external products are not being dated upon opening and the home was advised to introduce this practice and discard tubs after one month of opening and tubes after 3 months of opening. Wellesley House Nursing Home DS0000017200.V297460.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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