Inspection on 13/11/05 for Wellfield House

This inspection was carried out on 13th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wellfield House 21/01/09

Wellfield House 15/01/08

Wellfield House 24/04/06

Wellfield House 12/07/05

Wellfield House 06/12/04

Wellfield House 28/06/04

Wellfield House 24/11/03

Wellfield House 06/08/03

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 38/42 Athol Road Whalley Range Manchester M16 8QN Lead Inspector Leslie Hardy Unannounced Inspection 13th November 2005 10:15 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 House DS0000042777.V266188.R01.S.doc Version 5.0 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 House DS0000042777.V266188.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wellfield House Address 38/42 Athol Road Whalley Range Manchester M16 8QN 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) 0161 881 9700 Wellfield Estates Limited Mrs Bernadette O`Rourke Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing at the home must comply at all times with the minimum levels set out in the Residential Forum Guidelines for staffing in Care Homes for Older People. Personal care only is provided for a maximum of 23 older people. Staffing levels must be regularly assessed depending on service users assessed needs. The service should, at all times, employ a suitably qualified and experienced Manager who is registered with the NCSC. 12th July 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Wellfield house is a care home that provides accommodation and personal care only for up to 23 older people aged 65 years and over The home was originally four terraced properties, which have been converted into one detached property. The accommodation for residents is provided on two floors accessed via a passenger lift and stairwells. The kitchen, laundry and storerooms are situated in the basement of the building with the main office on the second floor. There are fifteen single rooms and four shared rooms. The home has an enclosed garden at the rear of the property with seating available. Residents are able to access the garden via steps or ramps. The home is located to the south of the city centre in a quiet residential area within walking distance of the local shops. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was unannounced, was carried out by 2 inspectors and a pharmacy inspector on a Sunday morning, started at 10.15 am and lasted for 4 75 hours. During the inspection, 12 residents, 3 visitors and 5 staff were seen. The inspectors looked around the building, including the laundry and kitchen area. They also looked at all types of care records and admission procedures. Employment practices were reviewed. At the last inspection it was of concern that the majority of the requirements from the previous inspection report had not been complied with. The effects of the failure to comply with these requirements was of great concern to CSCI so immediately after that inspection the Proprietor and Area Manager for the home group were required to attend a meeting at which ongoing concerns and lack of action on these was discussed. An action plan was formulated and monitored. It is positive to report that action has been taken to address the majority of those concerns with the proprietor and manager already planning the action they must take to address all the concerns. During this inspection only a selection of key National Minimum Standards were assessed therefore to gain the full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well: What has improved since the last inspection? Assessment, care planning and recording so that the home is not only able to say that they can meet the needs of new residents, but once they are admitted show how they are meeting these needs. All residents’ records are now kept securely. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 6 The home has developed the complaints procedure so that they can show that complaints made to them are appropriately dealt with. Some bedrooms have been redecorated. All wheelchairs have footplates on them so that residents are able to put their feet safely out of the way whilst moving. New equipment has been installed in the laundry. Overall the management of the home has improved which should improve the care delivered to residents who will also benefit from the availability of training to existing staff and the induction programme for new staff. 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 House DS0000042777.V266188.R01.S.doc Version 5.0 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 House DS0000042777.V266188.R01.S.doc Version 5.0 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): 3 and 5 Assessments undertaken prior to admission should ensure that the home only admit residents they can appropriately care for. EVIDENCE: All residents had assessments undertaken prior to admission by referring agencies. The homes manager now saw all potential residents prior to admission to assess their needs. This assessment could then be used to ensure that the home was able to meet the resident’s physical needs and that appropriate equipment was available. The assessment also included the resident’s social and cultural needs. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 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): 7, 8, 9 and 10 The implementation of appropriate risk assessments and care plans for all residents meant that though most needs were identified and staff could aware of how those needs were to be met, further development is recommended. Risk assessments were used without in some cases the underpinning knowledge that will ensure correct use each time. Staff were positively recording residents daily lives and activities. As detailed in the pharmacist inspectors report some of the homes drug administration procedures could put residents at risk. EVIDENCE: All residents had plans of care that had been written using information from general assessments and risk assessments. The plans and risk assessments were reviewed regularly. It is recommended that plans need to be developed to include all identified needs including social and cultural needs and state how these were going to be met. Some of the risk assessments used are open to interpretation and it is recommended that training be obtained in the completion of these and the how to interpret the definitions behind the categories within them. Good daily recording by staff complemented the planning and reported on the resident’s day and how this had been and their Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 10 response to interventions. It is recommended that these records be kept with the care plans so that staff are aware that the care plans are a working document that need to be referred to regularly. Records of visits by and the involvement of NHS staff such as G P’s District Nurses, Occupational and Physiotherapists Therapists were available, but not all records were fully completed which meant that records were not consistent and accurate. The involvement of residents and relatives in care planning must be recorded. One relative did confirm knowledge and involvement in his father’s plans. The homes management of medication was reviewed by the pharmacy inspector who was part of the inspection team. A number of concerns were raised and these are the subject of a separate report which to give a full picture needs to be read in conjunction with this report. Staff were seen to treat residents with respect and uphold their dignity. Residents and visitors confirmed that staff treated residents as individuals. Staff spoke to residents when undertaking personal care so the resident was informed of what staff were doing. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 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): 12, 13, 14 and 15 The home does not offer many activities, but it was not clear if this was to meet resident’s wishes. Open visiting hours enabled visitors to come when they wished. The home did offer some choice to residents and control over their day. The home need to continue to progress the actions they have started on meeting cultural needs, including meals for all its residents. EVIDENCE: There are little organised activities on offer in the home and residents spend a lot of time in a number of lounges talking or watching TV. One resident stated they were bored but on occasions had played board games with staff which she said she had enjoyed. There was some evidence of trips out of the home. It is recommended that the manager asks each resident what activities, if any, they would like to do and uses this as a basis for the future provision of any activities. The home had open visiting and visitors were seen throughout the inspection. One visitor who said they visited daily was happy that he could visit whenever he wished and was always made to feel welcome. Residents said that they got up and went to bed at a time they choose and were seen to exercise some choice about were they spent their day in the Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 12 home. Residents were seen to have choice over the clothes their wore, but a number of residents had bare feet or were just wearing socks. In one case this was following a physiotherapy assessment and advice, but in other cases this was not clear. Residents should be enabled to wear the footwear of their choice for not only comfort but also safety. The meal served at lunch was a roast meal that was appreciated by residents. The home has a number of residents from other cultures and one resident commented that though they had did have “cultural food” a couple of times a week he would prefer this every day. The manager spoke about how she was addressing this issue by using a visitor with an African Caribbean background to assist the chef with menu’s and techniques to address the needs of African Caribbean residents. This needs to be extended to address the needs of residents from other cultures. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 13 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): 16, 17 and 18 The home was recording complaints appropriately. Records were found to be kept securely. The manager should look too ongoing training for staff regarding adult abuse. EVIDENCE: A review of the homes new complaints recording procedure showed that since the last inspection on complaint had been received and this had been dealt with appropriately. Residents records were securely kept to ensure that only people with a right to see them could. The home has a copy on displace of the adult abuse procedure. Staff must receive regular update training on what is adult abuse and how they should respond in the event of this being suspected. This will ensure that residents are protected from abuse as much as possible. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 14 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): 22, 23 and 26 The home had adequate supplies of aids and adaptations but these must be kept in working order. The home was generally clean and odour free. Written confirmation is required that the new washing machine is fit for purpose. EVIDENCE: The home has appropriate aids and adaptations available to meet the needs of service users including wheelchairs being fitted with footplates to ensure residents safety. Two bath hoists which had been appropriately serviced were not able to be used because the batteries had not been charged. Batteries for such equipment must be kept charged so that the equipment can be used when needed. Bedrooms were pleasantly furnished and contained resident’s personal items. The home had recently purchased a new washing machine and dryer. The proprietor must confirm in writing with the supplier that the washing machine Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 15 had both a sluice cycle and wash able to hold the water temperature for the recommended period to disinfect items requiring this. The home was kept clean and was free of odour apart from one staircase were a laundry bag had been placed at the start of the inspection. Some light bulbs did not have shades, which can give an uncared look. The curtain tracking in two beds rooms was loose and the manager stated that it was due for repair the following day. The home did not have a clinical waste contract but disposed of incontinence pads in the general waste. The proprietor must receive written confirmation that this is acceptable to the local waste authority. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 16 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): 27, 28, 29 and 30 The home was providing appropriate numbers of staff per shift to met the current care needs of residents. Though progress had been made on recruitment practices since the last inspection these could still allow inappropriate staff to be employed putting residents at risk. Staff training was now taking place and an induction programme was available to ensure that new staff were appropriately inducted. EVIDENCE: Staffing at the home met the minimum staffing hours required as condition of registration. This included twenty hours of the manager’s hours being utilised as care hours. This was based on the number of residents at the time of the inspection and the level of dependency of those residents as identified by the manager. If the number of residents increased the care hours would have to do so to meet the needs of the additional residents. The manager was reminded that as part of the review of care she was required to review the staffing hours allocated in accordance with the Residential Forum Guidance. The manager had worked on the homes recruitment policies and practices since the last inspection. References were being obtained prior to commencement of new staff, but there needs to be evidence to demonstrate that these are provided in response to a request by the home. Criminal Records Bureau (CRB) checks were being undertaken once staff commenced Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 17 duty. It is required by statute that all staff must have Protection of Vulnerable Adult (POVA) clearance that is included in CRB checks but can be undertaken separately and quickly if the home is short of staff. As stated in the last report there is still the risk that inappropriate staff could be employed. Evidence of some staff training was seen including recent moving and handling training. New staff now had an induction programme. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 18 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): 32, 33, 34 and 38 The management of the home was stronger than at the last inspection but further action is required to make this robust and reduce the number of hours the manager worked. The availability of the manager provided positive reassurance for visitors. Formal staff supervision does not occur and means that staff are not able to talk about and reflect on the care they give and discuss ways of improvement to the benefit of residents. EVIDENCE: Following discussions between the proprietor, manager and CSCI inspectors following the last inspection, evidence was seen at this inspection of efforts to effectively manage and direct the home, including involving staff in risk assessments and planning. The manager was at the time of the inspection working over 48 hours a week out of choice and stated that it was two weeks since she had last had a day Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 19 off. It is recognised by both the manager and proprietor that support to the manager is needed and the manager stated that an advertisement was being placed in the regional evening newspaper that week for a deputy. One visitor commented on the fact that the manager was readily available, and he felt that she would deal with any concerns, if he ever had any. Residents and visitors were satisfied with the level of care in the home. None of the staff at the home were receiving supervision, which should occur at least six times a year. This will ensure that staff have the opportunity to discuss the care they are delivering which should enable a higher standard of care to be given to residents. Most fire doors were found at this visit to be kept closed but staff must be reminded that to keep a fire door open with anything, including as seen, slippers could put residents at risk in the event of a fire. Regular maintenance and servicing of equipment was being undertaken to ensure that they were fit for purpose. Sixteen emergency lights were not functioning when serviced recently. The proprietor must confirm in writing that these are now working. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X 3 3 X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 3 X X X 2 Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 21 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 2 3 Standard OP7 OP9 OP12 Regulation 15 13(2) 16(2)(n) Timescale for action The involvement of residents and 01/03/06 relatives in care planning must be recorded. The requirements from the 01/03/06 pharmacists report at this inspection must be implemented. A review of the availability of 01/03/06 activities must be undertaken to ensure that residents’ needs are being met. The continuing review of the 01/03/06 availability of food for residents from minority ethnic groups must ensure that the needs of all residents are met. Training on the recognition and 01/04/06 reporting of adult abuse must be available for all staff. Aids within the home must be in 01/02/06 working order at all times. The proprietor must provide 01/02/06 written confirmation that the new washing machine is fit for purpose. The proprietor must seek written 01/02/06 confirmation for the local waste disposal authority that the current practice for disposal of clinical waste is acceptable. DS0000042777.V266188.R01.S.doc Version 5.0 Page 22 Requirement 4 OP15 16(2)(i) 5 6 7 OP18 OP24 OP26 13(6) 23(2)(n) 13(3), 16(2)(e) 13(3) 8 OP26 Wellfield House 9 OP29 10 OP29 11 OP38 The service provider must a) ensure two appropriate references are obtained for all new staff prior to commencement of employment b) obtain CRB and POVA checks on all staff. (Previous dates of 28/02/05 and 01/10/05 not met). Staff members must receive individual supervision at least 6 times per year. A record of these sessions must be maintained. (Previous dates of 28/02/05 and 01/10 05 not met The proprietor must ensure that fire doors are never wedged open and confirm in writing that the emergency lighting is working appropriately 01/02/06 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP7 OP7 OP14 Good Practice Recommendations The care plan should state all identified needs are going to be met. Daily records should be kept with care plans to ensure they are available for staff to easily refer to. Ensure that all external visits are recorded so that a full picture of care for each resident is recorded.. Residents should be enabled to wear the footwear of the choice, ensuring foot protection when required. Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Wellfield House DS0000042777.V266188.R01.S.doc Version 5.0 Page 24 - 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. 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