Inspection on 16/08/05 for Wellfield

This inspection was carried out on 16th August 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

Wellfield 20/02/07

Wellfield 08/03/06

Wellfield 07/12/04

Wellfield 14/07/04

Wellfield 10/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Wellfield House 200 Whalley Road Accrington Lancashire BB5 5AA Lead Inspector Lynn Mitton Unannounced 16 August 2005 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. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wellfield Address 200 Whalley Road Accrington Lancashire BB5 5AA 01254 235386 01254 237022 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) Mrs Nesta Dianne Lynskey Wellfield and Henley House Ltd Care Home Only Personal Care (PC) 29 Category(ies) of Old age, not falling within any other category registration, with number (OP) 29 of places Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The service shall, at all times employ a suitably qualified and experienced manger who is registered with CSCI. Date of last inspection 07 December 2004 Brief Description of the Service: Wellfield is registered with the Commission for Social Care Inspection to provide accommodation and personal care to 29 older people. The property is Victorian and set in well maintained gardens. The home is located on the main Whalley Road and is close to local shops, and is on a main bus route to all areas of Hyndburn. Accommodation is provided 27 single rooms and one shared double room. Fourteen of the single rooms have en-suite facilities. There were four communal lounges and a dining room/conservatory. Smoking is permitted in a specially designated area. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 8 hours. There were 25 residents accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection three of the staff on duty, approximately 12 residents plus the registered provider and deputy manager were spoken to, and interaction between the residents and staff members were observed. Throughout the report there are various references to the “case tracking” process, this is a method whereby the inspector focuses on a small representative group of service users. Records pertaining to these people were inspected. Policies and practices were also read. Five residents had completed the Commission’s service users survey. These indicated that overall they were very happy with the level of service received at Wellfield House. There had been one complaint to the Commission since the last inspection; the outcome of this was documented separately to this report. What the service does well: One resident said “ The carers are very nice, you can’t fault them”. Another resident said, “They can’t do enough for you here, its marvellous!” Many of the care staff team had considerable experience in caring for older people, and were well established at Wellfield House, ensuring continuity for residents, and there was evidence to suggest that the care staff and manager ensured that routines were set around the needs and choices of the residents. Written information was in place for each resident regarding their care and health needs and how they were to be met. Any identified risks and how they were to be managed was also recorded. There were written procedures for dealing with complaints in place, and care staff and residents spoken to were aware of the procedures to follow. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean. Resident’s rooms were homely and personalised. Many had an en-suite provided. The homes gardens were well tended and in full bloom. Wellfield F57 F07 S9425 Wellfield V242584 160805 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. Wellfield F57 F07 S9425 Wellfield V242584 160805 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 Wellfield F57 F07 S9425 Wellfield V242584 160805 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) 2 & 6 A written contract, explaining the responsibilities of both parties, should be fully completed and issued to each resident. EVIDENCE: Contracts explaining the terms and conditions of residents stay at Wellfield House still had not been implemented. The inspector was advised that now the purchasing local authority had issued the new costings, this could now be done. Intermediate Care is not offered at Wellfield House. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 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 Care plans contained sufficient detail to ensure that all care needs were identified, documented and being met. EVIDENCE: The inspector looked at two residents care plans. On them was information identifying the resident’s care and health needs, and how these were to be met by the care staff team. There was evidence that one care plan had been reviewed in July 2005, the other had not been reviewed since June 2005. There were records of health needs being met and of risk assessments being completed in order to establish and ensure residents continued safety. One resident told the inspector, “I’m very well looked after here”. Observations made of one residents personal care during the inspection were discussed with the registered person, and also how the home meets the needs of residents with profound hearing losses was also discussed. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 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 Visitors to residents at Wellfield House were made welcome. The introduction of a regular in house programme of planned activities would ensure that residents had regular opportunities for their enjoyment, mental and physical stimulation. EVIDENCE: One resident said “I have visitors every day”. The inspector noted a number of visitors to the home on the day of the inspection. On the Commissions service users survey, 3 out of the 5 respondents indicated that suitable activities were “not” or only “sometimes” provided. It was noted that a trip to Blackpool was planned for October, and some residents were already looking forward to this trip. Concerts were organised in the home approximately every month. The management of one resident, whose behaviour was challenging was observed by the inspector and this was discussed with the registered person. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 11 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 Staff spoken to were aware of their role to protect the residents in their care. There were written procedures for dealing with complaints in place, and care staff and residents spoken to were aware of what to do if they wanted to make or received a complaint. EVIDENCE: There had been one complaint to the commission since the last inspection; and this was investigated during the inspection. The outcome of this was documented separately to this report. Documentation was in place regarding how to make a complaint and what procedures would be followed on receipt of a complaint. Residents spoken to could tell the inspector who to complain to and felt confident that their concerns would be listened to and acted upon. One resident said, “If I’d a complaint I’d talk to the boss”. Staff spoken to were had some idea of what they should do if they received a complaint from a resident or relative. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 12 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) 26 The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean. EVIDENCE: One resident said, “I’ve got a nice bed, the food is good and I’m very comfortable here”. Another resident told the inspector “it’s like being at home”. The inspector toured the communal areas and some bedrooms in the home. There were four communal lounges and a dining room/conservatory. Some residents spent much of the time in their own room. Residents spoken to said they were happy with this arrangement. Resident’s rooms were furbished with their own belongings and appeared homely and personalised. There was 1 bedroom with a localised area of odour detected. The inspector was assured this would be remedied as a matter of urgency. The home was clean and tidy, ensuring a pleasant environment for people living at Wellfield House. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 13 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) 28 & 30 Residents will benefit once more staff are trained to NVQ level 2 standard. Other staff training had been undertaken to ensure that staff were able to undertake their role with competence, in particular with reference to health and safety. EVIDENCE: The inspector was told by a resident “the carers are very nice, you can’t fault them”. Two out of the 22 care staff team had completed their NVQ level 2 training. 4 had obtained their NVQ 3 training certificate. A further 10 were undertaking NVQ 2 training, beginning in September 2005. 6 staff had completed emergency 1st Aid training, and 10 care staff were undertaking Medication Management training. In house moving and handling training had been undertaken in March 2005. The inspector observed residents being supported by competent staff. The deputy manager was due to begin her A1 Assessors training in September 2005. Two of the cooks had renewed their Food Hygiene certificates in April 2005. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 14 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) 33 & 38 The attitude of the staff and management was to run the home around the needs and choices of the residents. The fire and evacuation drill must be routinely checked in order to safeguard the health and safety of the residents and staff team. EVIDENCE: The inspector was satisfied that due to the daily involvement of the registered persons, and following observations made on the day of the inspection, that the satisfaction of the residents was of high priority. The quality monitoring format had been implemented and a resident survey had been completed in January 2005 the results of which had been published. The inspector was advised that a further survey was due to be conducted in the near future. The inspector advised that the survey form be dated. The inspector noted that the fire system had last been independently checked within the last 12 months. The last fire drill had been conducted in March 2005 Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 15 and was therefore overdue. There had been at least 2 monthly fire tests missed this year. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 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 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x x x 2 Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 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 OP2 Regulation 5(1b) Requirement The registered person shall provide all service users with a contract/statement of terms and conditions with the home. The registered person must ensure all aspects of health, personal and social care needs of the residents are reviewed and updated to reflect changing needs. The home must be free from offensive odours. The registered person is required to ensure that a minimum of 50 of staff who deliver personal care to service users achieve a NVQ Level 2 in Care Award. The registered person must ensure that fire drills are held on a regular basis ensuring that staff and residents are familiar with the processes. Timescale for action 4th November 2005 16th September 2005 2. OP7 15 3. 4. OP26 OP28 16(1k) 18 (1) (a) & (c) 16th September 2005 1st April 2006 5. OP38 23(4) 16th September 2005 Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 18 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 OP12 Good Practice Recommendations Regular, planned activities should be undertaken within the home and records of these should be made. Wellfield F57 F07 S9425 Wellfield V242584 160805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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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