Inspection on 24/04/06 for Wellfield House

This inspection was carried out on 24th April 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 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 House 21/01/09

Wellfield House 15/01/08

Wellfield House 13/11/05

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 Sue Jennings Key Unannounced Inspection 26th April 2006 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 House DS0000042777.V291357.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. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 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.V291357.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Personal care only is provided for a maximum of 23 older people. 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. 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. 13th November 2005 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.V291357.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key inspection of Wellfield House was unannounced and took place over the course of 4.5 hours on Wednesday 26th April 2006. Time was spent speaking to the registered manager, the area manager and the proprietor, 3 residents and 2 students who were on work placement. A random sample of care plans and staff recruitment files were examined and members of staff were observed as they went about their day-to-day routines. During this inspection the majority of requirements from the previous inspection had been addressed and there was evidence that this home was working hard to develop the service and meet the National Minimum Standards. As this inspection only looked at a limited number of standards this report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the residents living there. What the service does well: The standard of cleanliness throughout the home was good. One resident said “it is always clean”. The home assessed prospective residents care needs before their admission to the home to ensure their needs can be met. Further comments received by residents included “ I like it here and the staff are nice”, and “I am well looked after”. One relative said “the cook is really good he takes time out to come and speak to the residents”. During the inspection it was obvious that the registered manager was very visible and approachable. The residents spoke to her as she walked past The home had a warm friendly atmosphere and staff were observed to be pleasant and courteous with residents. Staff were seen to have good interactions with residents and were observed dealing with residents individual needs. During the inspection one of the work placement students translated for the inspector. Meals appeared to be nutritious, nicely presented and residents can choose what and when they eat. Comments from residents were positive and included comments like “ the food is good and you get plenty of it”, “you can have whatever you want to eat the cook is good”. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 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 House DS0000042777.V291357.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 Wellfield House DS0000042777.V291357.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): 3 and 6 The home undertakes an assessment of prospective residents care needs prior to their admission. Information is provided to residents and they are able to visit prior to making any decisions about their future. EVIDENCE: The home completes a pre-admission assessment with all prospective residents. A random sample of 3 pre-admission assessments were examined the assessment document comprised of a number of tick boxes and provided enough information to compile the initial care plan. Where possible, prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. All residents were reviewed after 6 weeks as a matter of course before a decision regarding permanent residency was made. The review meeting consisted of the resident, relatives, the registered manager and the Care Manager. This home did not provide intermediate care services. Wellfield House DS0000042777.V291357.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): 7, 8 9 and 10 The home had continued to make progress in improving the care planning process and had improved the arrangements to ensure that the health and personal care needs of the residents are identified and met, however more work was needed in this area. Residents are treated with dignity and respect. EVIDENCE: It was noted that the home had continued its efforts to improve the standard and usability of the individual plans of care, however the care plans did not fully reflect the residents needs or give clear detail of the action required to meet those needs. There was little evidence to show that residents or their representatives had been involved in the planning of care. The area manager reported that the home was in the process of implementing a new care planning system, which will be used throughout the company. The current care plans were fragmented and need to be set out in a user-friendly format. Each resident was registered with a General Practitioner (GP). A GP was visiting the home on the day of the inspection. Residents could see their GP in the privacy of their own room. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 Page 10 Evidence was seen of referral to other specialised services according to residents assessed needs including District Nurses, Dentist, Dietician and Chiropodists. The Pharmacy Inspector had made several requirements in November 2005 following a specialist inspection. The home had met a number of the requirements and was in the process of implementing staff medication training, which will be provided by the new dispensing chemist. The pharmacy inspector has been asked to visit the home again to fully assess the medication systems. Wellfield House DS0000042777.V291357.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): 12, 13, 14 and 15 The home provided a good environment for the residents who live there with some activities provided. Residents were able to maintain contact with family and friends and were able to exercise choice and control over their lives however, the home need to continue to progress towards meeting cultural needs. EVIDENCE: Residents spoken to said that they were able to have visitors when they wanted. The menus had been developed on a 2-week rota in accordance with resident’s likes and dislikes. The residents made positive comments about the quality and quantity of meals. The manager reported that the home were addressing this issue by using a visitor with an African Caribbean background to assist the chef with menus 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.V291357.R01.S.doc Version 5.1 Page 12 The manager reported that one resident’s family bring in a traditional meal for their relative in the evenings. A more thorough inspection of the home’s catering facilities will be carried out at the next inspection. The manager had developed an activities file since the last inspection where any activities were logged. These included board games, bingo, cards and visits from outside entertainers. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 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 and 18 The home was recording complaints appropriately. There was a policy in place for the protection of vulnerable adults. EVIDENCE: The home had undergone major staffing changes over the past month and this has resulted in 9 new staff members being employed as a result not all staff had received training in what to do in the event of an allegation of abuse to ensure the safety and well being of the residents. The proprietor must ensure that all new and existing staff be made aware of what constitutes abuse and the appropriate action that needs to be taken in the event of an allegation of abuse. The manager reported that an adult protection training session was planned for May 2006. The home had policies and procedures relating to the protection of vulnerable adults, a copy of the Manchester Multi-Agency policy for the Protection of Vulnerable Adults from Abuse and a ‘Whistle Blowing’ policy. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 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): 19 and 26 The standard of hygiene was generally good both internally and externally. Specialist equipment was made available as required by individual residents to meet their needs. EVIDENCE: The home did not have a clinical waste contract but disposed of incontinence pads in the general waste. The proprietor should obtain confirmation in writing that this is acceptable to the local waste authority. The requirement to repair the hoist made at the last inspection had been met and the proprietor produced documentation to evidence this. All areas of the home had been decorated, however a number of armchairs were stained and required recovering or replacing. The proprietor stated that he was going to purchasing loose covers to improve the appearance of the chairs. Other furniture was of a domestic nature and of an adequate standard. Wellfield House DS0000042777.V291357.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): 29 The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. EVIDENCE: On checking a sample of files of recently employed members of staff it was noted that some gave the names of friends or family as referees. Where the home employs overseas workers every attempt was made to obtain a reference from the last employer. Where there have been no previous employers it was recommended that attempts should be made to obtain references from a respected member of the community to whom the applicant is known for example a member of the clergy, college tutor or GP. One relative fed back that “Immigration have been into the home and since then there have been a lot of changes to staff some don’t speak English”, another said “the home always appears to be adequately staffed, they are nice with the residents and they are good at contacting you if there is a problem”. There has been a significant turnover of staff recently and it is acknowledged that the proprietor is working towards providing mandatory training for all new staff. Wellfield House DS0000042777.V291357.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): 31, 36 and 38 The home had systems and procedures in place to promote the health, safety and welfare of the residents and staff. Formal staff supervision had not commenced and means that staff were not able to discuss ways of improvement to the benefit of residents. EVIDENCE: The area manager had been providing support to the manager since the last inspection. The manager also stated that there are plans to employ a deputy manager to assist in the day-to-day management of the home. The manager split her contracted hours between 20 hours management and 20 hours care. It was agreed that these hours would e clearly identified on the staff rota. The staff at the home had not yet received supervision however there was evidence to show that meetings had been planned. Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 Page 17 These should continue on an eight-weekly basis. The reason for the delay in meeting the requirement from the last report was due to the major staffing changes in the home. Regular maintenance and servicing of equipment was being undertaken to ensure that they were fit for purpose. The emergency lights identified as not functioning have been repaired and a certificate was seen in the maintenance file to show that these are now working. The front entrance door was fitted with a digital entry system, which was not linked to the fire alarm and required a code to exit. The proprietor must take advice from the Fire Safety Officer regarding the suitability of this type of locking system. Wellfield House DS0000042777.V291357.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 3 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 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 3 Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement Care plans must clearly reflect resident’s needs/identified risks and the action required to meet them. Recording in the daily report sheets must clearly reflect the care that has been delivered over a 24-hour period. The continuing review of the availability of food for residents from minority ethnic groups must ensure that the needs of all residents are met (previous timescale of 1/3/06 not met). Timescale for action 01/06/06 2. OP15 16(2)(i) 01/06/06 Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 Page 20 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. 5. Refer to Standard OP7 OP7 OP19 OP26 OP29 Good Practice Recommendations The involvement of residents and relatives in care planning should be recorded. Daily records should clearly reflect the care delivered over a 24 hours period. The proprietor should arrange for the chairs in the lounge to be recovered. The proprietor should seek written confirmation for the local waste disposal authority that the current practice for disposal of clinical waste is acceptable. Where there have been no previous employers the proprietor should attempt to obtain references from a respected member of the community to whom the applicant is known for example a member of the clergy, college tutor or GP. Staff members should receive individual supervision at least 6 times per year. A record of these sessions should be maintained. The proprietor must take advice from the Fire Safety Officer regarding the suitability of the entry door digital locking system. 6. 7. OP36 OP38 Wellfield House DS0000042777.V291357.R01.S.doc Version 5.1 Page 21 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.V291357.R01.S.doc Version 5.1 Page 22 - 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!