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Inspection on 09/02/06 for Wellesley House Nursing Home

Also see our care home review for Wellesley House Nursing Home for more information

This inspection was carried out on 9th February 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

High levels of personal and physical care continue to be provided to all people living at the home. Residents and their representatives are being fully informed of the current changes and alterations to the environment. Residents are being consulted if a change of accommodation is required due to the planning of the phases of the building work.

What has improved since the last inspection?

It is acknowledged that some residents are not able or do not wish to participate in the care planning process, however, attempts have been made for the families and/or representatives to be involved on behalf of the residents. Their comments and input in the procedure are recorded in the case file.

What the care home could do better:

The bedrails and other equipment used at the home must be correctly fitted, suitable for the purpose and maintained at regular intervals.

CARE HOMES FOR OLDER PEOPLE Wellesley House Nursing Home 186 Penn Road Penn Wolverhampton West Midlands WV3 OEN Lead Inspector Joy Hoelzel Unannounced Inspection 9th February 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 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 Mrs Gillian Margaret Nicholls 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.V275952.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories (except 3 only terminally ill) Date of last inspection 7th June 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 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.V275952.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two and a half hours on Thursday 9th February2006 and is the second of the two statutory inspections for 2005/06. Twenty eight people were resident at the home at the time of the inspection, staffing levels were seen to be in line with minimum requirements, the owner, first level nurse, and seven care staff on duty, with additional domestic and catering staff. Contractors are currently on site extending and refurbishing the existing building, to increase the number of single occupancy rooms to accommodate thirty seven people. All bedrooms will have an ensuite facility. This inspection mainly focused on the ‘key’ standards that were not inspected during the inspection in June 2005. A tour of the building took place, relevant documents were examined, discussions were held with residents, four visitors and four members of staff. What the service does well: What has improved since the last inspection? It is acknowledged that some residents are not able or do not wish to participate in the care planning process, however, attempts have been made for the families and/or representatives to be involved on behalf of the Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 6 residents. Their comments and input in the procedure are recorded in the case file. 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.V275952.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not inspected on this occasion, but were included in the announced inspection in June 2005. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 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 the following standard(s): OP, 7, 10 Staffs are sensitive to the individual needs of each service user and meet these in a professional manner EVIDENCE: The representatives of the residents are being consulted and involved in the care planning process whenever possible. A record is made of their involvement and included in the case file. It is acknowledged that some residents are too frail to partake and others do not wish to do so. Staffs were observed to be knocking on bedroom doors prior to entering; one resident was being helped back to the bedroom in preparation for a doctor’s visit. The residents appeared very much at ease with all staff on duty and good interaction was observed. Bed curtains are provided in shared rooms to ensure privacy is upheld. The planned alterations ongoing at present will further uphold a person’s privacy and dignity with the addition of all single occupancy bedrooms and en suite facilities. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 10 Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 11 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 14 In consultation with individuals living at the home or their relatives if appropriate, choice and control over every day living is promoted where possible. EVIDENCE: The contact details of the advocacy service are clearly displayed on the notice board. Residents are encouraged to bring their personal possessions with them into the home and many rooms were highly individualised. The owner explained that some residents had requested alternative accommodation in another area of the building on completion of the building works. Other residents had stated that although they realise that a temporary move is necessary they would like the guarantee that they are able to move back into their own rooms in due course. The owner stated that she feels she will be able to facilitate these requests. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 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 the following standard(s): OP 16, 18 The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon. EVIDENCE: The complaints procedure is clearly displayed on the notice boards around the home. No complaints have been made either to the home or Commission for Social Care Inspection since the inspection in June 2005. The owner and manager have a good knowledge of dealing with concerns and complaints and have developed good relationships with the visitors to the home. One visitor stated that she would talk to the owner if she had any concerns. Training in adult abuse awareness has been arranged for staff later on during this month. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 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 the following standard(s): OP 19,22 The current changes being made to the environment will further enhance the standard of the living conditions for the people at the home. EVIDENCE: The home continues to provide a comfortable environment for the people living at the home. One visitor confirmed that she had been kept fully informed of the programme for the building works and that the potential impact of the additional noise and disruption had been kept to an absolute minimum. The owner stated that all bedrooms are to be refurbished and redecorated and are included in the plans for the upgrading of the premises. The owner stated that at the different phases of the building work, some residents would have to change rooms and move into a different area. Residents and their families have been consulted on this, with the owner ensuring that their wishes will be taken into account when the work is completed. It is anticipated that the building works, refurbishing and redecorating will be completed in May 2006. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 14 Most beds have been fitted with bedrails, on inspection it was noted that some had been fitted that were not compatible with the type of bed in use. The owner stated that due to some changes to the accommodation, the rails had not been fitted properly. A full check of all bed rails and their suitability for each bed is required. The owner stated that she would personally see this was carried out expediently. A care plan evidenced that a risk assessment had been carried out together with consent for the use of bedrails. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 15 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 29, 30 The people living at the home are supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner EVIDENCE: Two staff personnel files were examined and included a criminal record bureau disclosure, proof of identification and employment contract. All new employees receive a full induction programme; a record of this is kept in the personnel file. Training and development needs are identified through the appraisal system and opportunities for training in the core and specialist topics are arranged. The deputy manager explained that specialist awareness topics are being arranged for staff and include awareness of dementia, diabetes and strokes. National Vocational Qualification at levels 2 and 3 continue for care staff. The administrator arranges the training courses and ensures that each staff member has a training schedule. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 16 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, 33,38 There are clear lines of accountability within the home’s management structure; the management approach creates an open and positive atmosphere from which the residents benefit. EVIDENCE: Plans have been made for the imminent retirement of the registered manager later on in the year. A deputy manager has been working closely with the manager and it is anticipated that she will take over the role in due course. The deputy demonstrated a good knowledge of the resident group and the conditions and challenges associated with ageing. Staff meetings continue on a regular basis, minutes are produced and available for staff that did not attend. Satisfaction questionnaires are sent periodically to relatives, with the manager auditing the results. The owner has suspended other systems and procedures for monitoring quality assurance until completion of the building works. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 17 Safety checks continue weekly, monthly or annually and records are kept. The requirement for the testing of all portable appliances has been carried you. Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 19 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. 1. Standard OP22 Regulation 23(2)(n) Requirement The registered person must ensure that all bedrails are compatible with the bed and they are correctly fitted. The registered person must ensure that regular maintenance checks are made for all bed rails in use and records kept. Timescale for action 17/02/06 2 OP22 23(2)(n) 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wellesley House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Wolverhampton Area Office 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 House Nursing Home DS0000017200.V275952.R01.S.doc Version 5.1 Page 21 - 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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