CARE HOMES FOR OLDER PEOPLE
Wellington House Nursing Home 82-84 Kirkgate Shipley West Yorkshire BD18 3LU Lead Inspector
Mary Bentley Unannounced Inspection 24th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wellington House Nursing Home DS0000019860.V278191.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. Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Wellington House Nursing Home Address 82-84 Kirkgate Shipley West Yorkshire BD18 3LU 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) 01274 531244 01274 596573 Wellington House Nursing Home Limited Miss Alison Jane Pitts Care Home 33 Category(ies) of Physical disability over 65 years of age (33) registration, with number of places Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th July 2005 Brief Description of the Service: Wellington House is a Victorian property with a purpose built extension standing in its own grounds. The home has been established for 17 years and is registered to provide personal and nursing care to a maximum of 33 older people. The home provides care for male and female service users. The home has a no smoking policy. The home is well maintained both internally and externally. Accommodation is provided in 19 single and 7 double rooms; 15 rooms have en-suite facilities. There is ample provision of communal space and access is provided to all areas of the home by means of a passenger lift and stair lift. The home is situated close to Shipley town centre and is geographically convenient for Bradford and Leeds. The home has well tended gardens and car parking is provided on site. Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of this home and it was unannounced; the first inspection was announced and took place in July 2005. One inspector carried out the inspection and spent approximately five and a half hours in the home. There have been no additional visits to the home since July 2005. The methods used during the inspection included talking to relatives, residents, staff and management. We looked at care records and carried out a tour of the home. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are discussed with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection?
Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 6 There have been no complaints since the last inspection. Work is progressing on implementing the new format for care plans. The home has put together a Welcome Pack that is given to all new residents; this provides detailed information about the home in a clear and well-presented style. The programme of refurbishment has started. 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. Wellington House Nursing Home DS0000019860.V278191.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 Wellington House Nursing Home DS0000019860.V278191.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): These standards were not inspected on this visit; please see the report dated 27 July 2005 for details. EVIDENCE: Wellington House Nursing Home DS0000019860.V278191.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 & 10 Residents’ needs are met in a way that respects their privacy and dignity and takes account of their wishes. EVIDENCE: The home has started to implement a new format for care planning. The new format is designed to present care needs from the residents’ perspective and will be much easier for residents, their representatives and staff to use. The care plans set out how all aspects of health, personal and social care needs will be addressed and are reviewed monthly. A nutritional risk assessment has been introduced and staff have been trained on how to use this. Where risk assessments identify a resident as being at risk the appropriate care plans are in place for example with regard to pressure area care. There is a risk assessment for the use of bed safety rails but this does not give enough information to make it clear why bed safety rails were needed. The care plans showed that the home consults with other professionals such as GPs, the Tissue Viability nurse and dieticians about residents care needs. Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 10 Staff used screens to protect the dignity of residents when using hoists in communal areas; this is good practice. The home has a mobile pay phone that can be connected up in the bedrooms so that residents can make or receive phone calls in private; the home also has a cordless phone that can be used by residents. Wellington House Nursing Home DS0000019860.V278191.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): These standards were not inspected on this visit; please see the report dated 27 July 2005 for details. EVIDENCE: Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this visit; for details please see the report dated 27 July 2005. EVIDENCE: Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 Residents live in clean, comfortable and safe environment that is suitably equipped to meet their needs. EVIDENCE: The home was clean and free of unpleasant smells with the exception of two bedrooms were there was a slight odour. The home has started a programme of refurbishment; the rooms in the original part of the building will be done first. Rooms in the extension are decorated as they become vacant, as part of the refurbishment programme many of the existing bedroom carpets will be replaced. In the bedrooms seen residents had lots of their personal belongings around them, as well as memorabilia there were things such as books, magazines and jigsaws which showed that resident are supported in keeping up with their interests and hobbies. The bedrooms are comfortable and well equipped. Call bells are provided in all parts of the home used by residents. The programme of fitting door locks is ongoing; in the meantime locks are fitted at the request of residents.
Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 14 The home has a passenger lift; a stair lift and a wheelchair lift so that residents can have access to all parts of the home. The home is well equipped with bath hoists and mobile hoists. There are staff hand washing facilities in all the toilet and bathroom areas, and staff are provided with gloves and aprons. Waste is disposed of correctly and there is a clear policy on how to deal with both soiled and infected laundry. The laundry was clean and well organised; it was suitably equipped to meet residents’ needs. Wellington House Nursing Home DS0000019860.V278191.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): 27, 28 & 30 There are enough staff to meet residents needs. There is a good training programme that supports staff in understanding and meeting the needs of residents. EVIDENCE: Duty rosters are available for all grades of staff and staffing levels are reviewed regularly. Residents did not raise any concerns about the availability of staff to meet their needs. NVQ (National Vocational Qualification) training is ongoing, 38 of care staff are qualified to NVQ level 2 or above and three staff have BTEC certificates in care and/or health studies. The home uses its own induction format; the manager said she had recently attended training on the new Skills for Care induction standards and would be reviewing the homes induction to make sure it was compatible with these. There is a training plan to support staff in developing their skills and knowledge. Over the past 12 months training has been provided on a variety of subjects including moving & handling, infection control, wound care and tissue viability, continence, Parkinson’s disease, and healthy eating and food hygiene. Wellington House Nursing Home DS0000019860.V278191.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): 31,32,33 & 38 The interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. The home is well managed. EVIDENCE: The registered manager is a nurse with many years relevant experience; she has successfully completed the Registered Managers Award. The home has regular staff meetings and detailed notes of these meetings are given to staff that have been unable to attend. Staff said the management team supported them and any issues that arose were dealt with rather than being left to “fester”. The home holds regular residents meetings and these include discussions about the menus and plans for social events. The home produces a newsletter every two months, it contains information on past and planned social events, copies of the menus and information on things that are happening in the home
Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 17 such as the planned refurbishment and staffing changes. The newsletter is widely available; copies were seen in many of the bedrooms. Questionnaires were issued recently to all residents and/or relatives, at the time of the inspection most of them had been returned but had not yet been analysed in detail. The manager said an action plan would be put in place to deal with any issues that were identified and the findings of the survey would be shared at staff and residents meetings. Information provided by the home showed that equipment is serviced and maintained at the required intervals. Checks on the fire safety systems are done weekly and staff receive regular fire safety training. The home has a Health & Safety group that meets approximately every 3 months. Among other things the H&S group reviews all accidents that have occurred and looks at what if anything can be done to reduce the risk of similar accidents happening again. Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 X 2 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Wellington House Nursing Home DS0000019860.V278191.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 OP24 Regulation 12 Requirement The programme of fitting door locks to service users bedrooms must continue. Previously agreed timescale 30 December 2005 not met. Timescale for action 23/06/06 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. Refer to Standard OP8 OP35 Good Practice Recommendations The risk assessment for the use of bed safety rails should be reviewed. Two signatures should be recorded for all cash transactions. Carried forward from the last inspection. Wellington House Nursing Home DS0000019860.V278191.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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