Inspection on 07/06/05 for Wellesley House Nursing Home

This inspection was carried out on 7th June 2005.

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

Wellesley House Nursing Home 20/09/06

Wellesley House Nursing Home 09/02/06

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 Care Home 186 Penn Road Penn Wolverhampton WV3 0EN Lead Inspector Joy Hoelzel Unannounced 7 June 2005 10:00 th 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. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wellesley House Address 186 Penn Road, Penn, Wolverhampton, WV3 0EN 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) 01902 342195 01902 342195 Mr Stephen Cadman Mrs Gillian Nicholls Care Home 33 Category(ies) of Old Age (33) registration, with number Physical Disability (33) of places Terminally Ill (3) Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) No number division between categories (except 3 only terminally ill) Date of last inspection 04.02.2005 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. 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 it’s 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 planning to increase the number of single rooms by extending the property and converting the current double rooms to singles. The home is well managed and staff work hard to maintain high standards and a pleasant atmosphere. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two hours on Tuesday 7th June 2005 and is the first of the statutory inspections for 2005/06. Twenty nine people were resident at the home at the time of the inspection, staffing levels were seen to be in line with minimum requirements with the owner, first level nurse, and seven care staff on duty, with additional domestic and catering staff. A tour of the building took place, three care plans were examined together with supporting documents, discussions were held with six residents, five visitors and five members of staff. What the service does well: What has improved since the last inspection? What they could do better: Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 6 A more proactive approach to social, leisure and recreational activities may enhance the life style of some residents. One requirement made at the last inspection has yet to be fully complied with, this being the involvement of residents in the care planning process. It is noted that not all residents would wish to be involved but people must be given the opportunity to discuss the issues that apply to them. 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 Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,5,6 Prospective residents needs are assessed before moving into the home. Relatives are provided with the opportunity to visit the home to assess its quality, facilities and ability to meet an individual’s needs prior to admission EVIDENCE: A visitor stated that prior to making the decision for the relative to move into the home, he was able to visit and meet the staff and other residents, unfortunately his wife was unable to visit prior to moving in due to mobility and cognitive difficulties. He confirmed that a member of staff visited to complete an assessment of need before admission to the home. This assessment is then used to generate a plan of care. The home does not offer an intermediate care service. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 The care plans contain all the basic information that is required to fully meet an individuals needs. However, there is little evidence to suggest that residents are being consulted and involved in the planning of their care. EVIDENCE: The care plans are generated from the pre admission assessments and are reviewed at least monthly, they indicate that relatives are informed and aware of the use of bedrails, but there is little evidence to suggest that residents are being fully involved. One resident was aware of the care plan but commented that she had no involvement in the process, but stated she did not wish to be involved. She was willing to ‘let the staff do that’. Two care plans evidenced that the relatives had been consulted about the use of bedrails. The plans are easy to read and follow and include information of all identified care needs. Risk assessments are carried out and include the approach and management needed for the risk of falling, pressure areas and nutrition. Medication is stored in a locked trolley and is administered by the first level nurses, the medication administration records appeared to be fully completed and the general /practitioners consent has been obtained for the use of homely remedies i.e. the occasional use of paracetamol. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 10 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) 12,13,15 Whilst activities are provided within the home there is little evidence of consultation with service users regarding their preferences, and is dictated to a large degree on the time constraints of the care staff on duty. The meals provided are of a good homely type offering both choice and variety. EVIDENCE: The visitors at the home commented that they thought there were not enough social and recreational activities arranged either in the home or in the community. One relative commented that she had been told that the gardens are not accessible, and indeed on inspection the paved areas were seen to be uneven. However the garden areas are due to be revamped as part of the planned alteration and refurbishment programme. One resident stated that there was ‘not much going on’, another resident stated that he enjoyed watching the television and was able to do so whenever he wished. The owner discussed the previous outings, excursions and activities that had been arranged but spoke of the difficulties with mobility and accessibility of some of the venues. Activities continue to be arranged weekly with bingo sessions and entertainers in house. The visitors stated that they could visit the home at times to suit their relative and were always made welcome. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 11 All five residents spoken with stated that they enjoyed the food that was offered. The cook at the time of the inspection had only been at the home for three weeks but appeared to be making a good start and was observed to be preparing the lunch time meal which included fresh vegetables and fruit. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints procedure is adequate, with senior staff being accessible to deal efficiently with concerns and problems. EVIDENCE: No complaints have been referred to the Commission for Social Care Inspection. One visitor spoke of concerns that she has with her relatives stay at the home and some financial issues, she confirmed that she has spoken with the owner of the home regarding this. The complaint procedure is included in the statement of purpose and a copy is displayed on the notice boards. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home continues to provide a high quality, comfortable and safe environment for those in residence. EVIDENCE: The home offers single and twin occupancy accommodation, three residents and two visitors commented that they would like to be accommodated in single rooms. The plans in hand for the reduction of the double occupancy rooms to increase the number of single rooms will facilitate this request. The sitting and dining areas are well furnished, comfortable and homely. A suitable locking facility fitted to all bedroom doors is to be included in the plans for the refurbishment and alterations of the home. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 14 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, There is a stable staff group working positively and enthusiastically towards providing a high quality of care. EVIDENCE: Staffing levels remain at the agreed levels and are determined by the dependencies of the residents. At the time of the inspection seven care staff, one first level nurse and the owner were on duty, in addition were administration, domestic and catering staff. Visitors commented that staff always appeared to be very busy with little time to spare. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 15 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) 35,38 Health, safety and welfare of service users and staff are promoted by safe working systems in place EVIDENCE: The recently revised procedure for dealing with residents’ personal monies is robust. Individual wallets and recording sheets are used, with two signatures obtained for each transaction. Health and safety checks are routinely carried out. The annual safety tests for the portable electrical appliances are overdue. This was discussed with the owner at the time of the inspection. Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 16 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 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 3 x x 2 Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 17 yes 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 7 Regulation 15(2)(b) (c) Requirement The service users plan of care must be formulated and reviewed wherever possible with the involvement of the service possible and/ or representative (if appropriate). This is outstanding from the previous inspection and must be given priority attention All portable electical appliances must have the annual safety test. Timescale for action with immediate effect. 2. 3. 38 12(1)a) (b) 30th June 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. Refer to Standard Good Practice Recommendations Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor St Davids Court Union Street Wolverhampton WV1 3JE 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 Wellesley Care Home E56 000017200 Wellesley House v231730 UI 210605 Stage 4.doc Version 1.30 Page 19 - 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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