Inspection on 20/02/07 for Wellfield

This inspection was carried out on 20th February 2007.

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 08/03/06

Wellfield 16/08/05

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 200 Whalley Road Accrington Lancashire BB5 5AA Lead Inspector Mrs Lynn Mitton Unannounced Inspection 6th February 2007 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 Wellfield DS0000009425.V323452.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. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellfield Address 200 Whalley Road Accrington Lancashire BB5 5AA 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) 01254 235386 01254 237022 wellfield200@tiscali.co.uk Wellfield & Henley House Ltd *** Post Vacant *** Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service shall, at all times employ a suitably qualified manager who is registered with the Commission For Social Care Inspection. 8th March 2006 Date of last inspection 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. Fees for the cost of a weeks care at Wellfield ranges from £320.00 – £360.50. There was information available to potential service users and their families advising them of the home and giving them details about the type of service they could expect. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 6th February 2007. The registered person completed a pre inspection questionnaire. The inspector spoke to residents in receipt of a service, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of residents. Records regarding these people were inspected. Three residents were case tracked, their files examined in detail and two care staff member’s files were also case tracked. Seven of the Commissions resident’s questionnaires were returned. Comments and findings of these surveys are referred to throughout this report. The inspector conducted the inspection with the registered person and senior carer on duty at the time of the inspection. During the inspection a number of records, policies and procedures were also viewed. What the service does well: One resident’s relative wrote: “the home has a very good reputation in the local area and is renown for its experience in caring for older people in a family atmosphere”. One resident’s relative wrote: “My mum seems happy at Wellfield, and I am pleased with the staff”. A contract was being issued to each resident when they moved into the home. Care plans contained information to ensure that care and health needs were identified. Medication was being stored or administered in a way that ensured resident’s safety was maintained. Residents appeared to be cared for in a way that promoted choice, dignity respect and fulfilment. Residents were also given opportunities to exercise choice and control in their day to day living. Visitors to residents at Wellfield were made welcome. Meals were varied and provided a social occasion on a daily basis. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 6 Complaints policies and procedures were in place and on clear view and available to residents and the homes visitors. Staff spoken to were aware of their role to protect the residents in their care. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean. State of the art laundry facilities were in place. There were sufficient staff on duty to meet service users needs. The attitude of the staff and management is to run the home around the needs and choices of the residents. Residents and regular visitors to the home were being consulted about the day-to-day running of the home. 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. The summary of this inspection report can be made available in other formats on request. Wellfield DS0000009425.V323452.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 Wellfield DS0000009425.V323452.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP2, OP3 & OP6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A contract was being issued to each resident when they moved into the home. The admission procedure for new residents ensured that some information about their care needs was obtained before they arrived. EVIDENCE: One resident’s relative wrote; “we were already familiar with Wellfield so knew it was excellent”. One resident wrote; “Numerous relatives of residents spoke highly of the home”. Contracts explaining the terms and conditions of residents stay at Wellfield were in place for the resident’s case tracked. The inspector advised that all personal details, for example, date of admission, room number, fees and Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 9 payment details must be completed for all residents, and they must be signed by the resident or their next of kin and the registered person. The contracts case tracked were fully completed by the end of the inspection. The inspector saw three assessments of need, which had been completed prior to new residents being admitted. The inspector advised that as much detail as possible must be obtained about the prospective residents needs, and the author of the document must sign and date the assessment. Not all assessments seen had detailed information. Letters were sent to residents advising them that Wellfield was able to meet their needs. Intermediate care is not offered at Wellfield. Wellfield DS0000009425.V323452.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8 OP9 & OP10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contained information to ensure that care and health needs were identified. Medication was being stored or administered in a way that ensured resident’s safety was maintained. Residents appeared to be cared for in a way that promoted choice, dignity respect and fulfilment. EVIDENCE: The inspector looked at three residents care plans. Information was in place identifying resident’s care and health needs and how these should be met. There was information on each care plan demonstrating residents and or next of kin involvement, and each had been reviewed recently. Daily records were not completed each day; just when staff felt an occurrence worthy of note had happened. All case tracked had entries within the past week. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 11 On care plans case tracked there was information completed regarding their health needs, this included a nutritional assessment and weight records. Resident’s medication was administered by a NOMAD monitored dose system. The inspector examined the medication storage area and medication administration records. These were in order. On the care plan’s case tracked consent of administration of medication forms were seen. The inspector was advised that some care staff had completed mediation awareness training. Accredited medication administration training was ongoing. From observations, the inspector felt that staff knew residents needs well, and they were observed to treat them with dignity and respect. Wellfield DS0000009425.V323452.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 & OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of planned activities ensured that residents had opportunities for enjoyment, mental and physical stimulation. Residents were given opportunities to exercise choice and control in their day to day living. Visitors to residents at Wellfield were made welcome. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: One resident said; “I normally eat and enjoy whatever is served”. Another resident wrote; “My visitors and I always enjoy our meals at Wellfield, they are nicely presented, appetizing and enjoyable”. One resident wrote; “If it were possible more activities would be welcomed”. The promotion of individual and group activities was discussed with the registered person, and a record of activities on offer was now recorded. One resident has her budgie in her room. The Catholic representative visits the Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 13 home each week and the Church of England representative visits monthly. One resident goes to the local Methodist church each Sunday. There were a number of visitors to the home on the day of the inspection. One said she was “made very welcome”. The visitor went on to say she could talk to the staff team about any concerns she had about her relative. The inspector noted the 4 week rotating menu, this demonstrated a well balanced diet. Each day’s menu was written in the dining room on the wipe board for residents benefit. The inspector ate lunch with the residents on the day of the inspection. Residents were served alternatives to the main meal offered. Some residents chose to eat in their own room. The dining room had only enough tables and chairs to seat 16 residents. The inspector observed resident’s exercising choice and control over day-today elements of their lives. Care staff were seen to respect residents choices and opinions. Wellfield DS0000009425.V323452.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 & OP18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints policies and procedures were in place and on clear view and available to residents and the homes visitors. Vulnerable Adults policies and procedures together with staff training work to ensure the safety of the residents. Staff spoken to were aware of their role to protect the residents in their care. EVIDENCE: One resident wrote; “If I am not happy I will speak to any member of staff who will contact management if necessary”. Another resident’s relative wrote; “There is an open door policy, my relative would speak directly to her carer, or if I felt the need would speak directly to Mrs Lynskey”. There had been no complaints to the Commission or recorded by the home since the previous inspection. The complaint policy and procedure was in evidence in communal areas of the home. The complaints policy and procedure was seen this had been reviewed in September 2006. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 15 Staff spoken to by the inspector said they would refer any complaint to the management team, and if necessary give the complainant a complaint form. They said if they themselves could resolve the issue, they would do so. The home had a copy of the “No Secrets in Lancashire” document. The inspector noted there was a Prevention of Abuse policy in place. The inspector advised that further detail was needed in this document, for example if a criminal offence has taken place what action must be taken, prior to the homes own investigation. A whistle blowing policy was seen, this had been reviewed in September 2006. Staff spoken to could identify different types of abuse and knew what to do if they observed abusive behaviour by a colleague or resident. They were aware of whistle blowing. The inspector was advised that Prevention of Abuse staff training was due to be held within the next three months. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 & OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy and clean. Odour management in some areas of the home needed further attention. Laundry facilities were seen to be fit for purpose. EVIDENCE: One resident wrote; “My room is cleaned regularly and the lounges and dining room always look tidy”. The inspector toured the communal areas and most bedrooms in the home. New curtains had been hung in the lounges. The general layout and décor of Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 17 the home provided comfortable and clean surroundings, and was warm, tidy and clean, however, there were localised areas of odour detected in four bedrooms. There were room passports, which indicated when each room had last been cleaned, decorated or maintained. However, not all these records were up to date. The inspector was advised that general ongoing maintenance to ensure the upkeep of Wellfield House continued. Laundry facilities were seen and industrial standard washers and dryers were in place. The inspector noted that a new Otex ozone system had been installed, which will eradicate the risk of dangerous superbugs. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28 OP29 & OP30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff on duty to meet service users needs. 80 of care staff were trained to NVQ level 2 standard. Staff training ensures that the care staff team are able to competently care for the service users. More focussed induction training would ensure that new care staff are aware of the needs of the residents. EVIDENCE: One resident wrote; “everyone is friendly and helpful, and they respond quickly to any requests”. The staff rota was seen and this demonstrated which staff were on duty at any time during the day or night. There were usually 4 care staff on duty from 8 am until 1pm and 3 care staff from 1pm until 6pm, and 4 care staff on from 6 – 10pm. 3 care staff were on wake and watch duty overnight. The registered person was included on the rota. Many of the care staff team had considerable experience in caring for older people, and were well established at the home. There were cooks and cleaners and a handyman also employed. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 19 The inspector was advised that 17 out of 21 care staff had now obtained NVQ 2 care qualification. A training matrix had been completed which demonstrated which staff had undertaken training. The inspector observed residents being supported by competent and caring staff. Two staff recruitment files were case tracked and both were found to have minor shortfall in the documentation required by legislation. This shortfall was a photograph. The inspector noted that evidence of staff training was now available on care staff’s file. However, there was no evidence that either staff member case tracked had completed induction training. The inspector was advised that the new skills for care induction package had just been purchased and was due to be introduced in the near future. The inspector was advised that the registered person had diarised 1:1 supervision sessions for all the care staff team. The inspector was advised that team meetings were held every 6-8 weeks. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 & OP38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s finances were dealt with either by the residents or their family. The attitude of the staff and management is to run the home around the needs and choices of the residents. Residents and regular visitors to the home were being consulted about the day-to-day running of the home. Checks to ensure the health and safety of residents and care staff were in place. Further health and safety training for staff was needed. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered person was involved on a daily basis with the day to day running of the home. The inspector was advised that the registered person had undertaken a OU Certificate of Leadership and Management and is hoping to complete this in April 2007. The registered person was appointee for one resident; all other residents had all their monies dealt with by their next of kin. A Quality Assurance survey had been completed in September 2006. The results had been collated and published. The inspector was advised that a business plan had been completed, however a copy was not seen. The inspector noted that the fire audit/risk assessment had been completed, and the fire system had last been independently checked in November 2006. The last fire drill had been conducted 4/2/07. Fire awareness training had been undertaken in Nov 06. There had been a Gas Safety check completed in September 2006. A portable appliance test had been completed in December 2006, however the 5-year electrical wiring certificate was dated April 2006. Other health and safety certificates were seen and in place. Standard risk assessments were in evidence on care plans case tracked, for example moving and handling, waterlow, mobility and tissue. The inspector and registered person discussed the need to have risk assessments in place for the home. Some health and safety training was outstanding, for example, moving and handling and 1st Aid. The inspector was advised that this was ongoing. Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 22 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 3 2 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14(1) Requirement The registered person must assess the needs of prospective residents prior to their placement at the home. The registered person must ensure that by staff training or other measures, to prevent residents from harm, abuse or being placed at risk or harm or abuse. Facilities at the home must be kept odour free and safe. The registered person must operate a thorough recruitment process at all times. Persons working in the care home must receive training appropriate to the work they perform. Unnecessary risks to the health and safety of the service users are identified and as far as possible eliminated. Timescale for action 29/06/07 2. OP18 13(6) 29/06/07 3 4 OP19 OP29 23 (2) 19 Schedule 2 12, 18 1(a&c) &19 13(4 b&c) 29/06/07 29/06/07 5 OP30 31/08/07 6. OP38 31/08/07 Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 24 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 Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Wellfield DS0000009425.V323452.R01.S.doc Version 5.2 Page 26 - 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!