Inspection on 27/07/05 for Wellington House Nursing Home

This inspection was carried out on 27th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellington House Nursing Home 17/04/07

Wellington House Nursing Home 24/01/06

Wellington House Nursing Home 02/03/05

Wellington House Nursing Home 08/06/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOMES FOR OLDER PEOPLE Wellington House 82-84 Kirkgate Shipley West Yorkshire BD18 3LU Lead Inspector Mary Bentley Announced 27 July 2005, 9.30am. th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wellington House Address 82-84 Kirkgate Shipley BD18 3LU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 531244 01274 596573 Wellington House Nursing Home Ltd Miss Alison Jane Pitts Care Home with Nursing 33 Category(ies) of Physical Disability Over 65 (33) registration, with number of places Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02/03/05 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 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 J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that time, the CSCI must do a minimum of two inspections of all care homes. This was the first inspection for this year. It was announced and carried out by one inspector between 9.30 am and 4.45 pm on 27 July 2005. The purpose of this visit was to assess whether the care given to residents meets the national minimum standards. The methods used in this inspection included discussions with residents’, staff and management, examination of care records, observing care staff carrying out their duties and looking at some parts of the home. The home prefers to use the term “resident” rather than “service user” therefore that will be used in this report. Comment cards were left at the home to be given to residents and relatives. These cards provide an opportunity for people to share their views of the home with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those completing them. What the service does well: Wellington House provides a clean, comfortable and homely environment for residents. Residents are encouraged to have their personal possessions around them and some residents have their own phones in their rooms. Residents spoken to were happy that their care needs were being met in a way that respected their privacy and dignity and said the staff were very good. Residents were satisfied that there were enough staff to meet their needs. From what was seen during the inspection and from conversations with residents it was clear the people are able to choose how and where to spend their time. Residents and/or their representatives are involved in planning how their care needs will be met and there are regular residents meetings where people living in the home are involved in planning the programme of activities and the menus. Residents said they enjoyed the food and were able to choose what they wanted to eat. The home offers a varied programme of activities, details of which are circulated in a regular newsletter. Staff said they felt supported by the management team and were encouraged to develop their skills and knowledge. The home holds the Investors in People Award. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5. Standard 6 does not apply to this home. People are helped to make an informed decision by the information they are given and from what they see when they visit the home. The needs of all prospective residents are assessed before admission. EVIDENCE: A Statement of Purpose is available. The Service User guide is presented in the form of a welcome pack and includes detailed information about the services and facilities offered, both of these documents are regularly reviewed and updated. Prospective residents are encouraged to visit the home but the manager said that in most cases it is the relatives who make the initial visit. The records showed that pre-admission assessments are done and on the day of the inspection the deputy manager went out to do such an assessment. The records of these assessments did not always show who had done the assessment, where and when it had been done and who had been involved. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 Residents are treated with respect and dignity. Residents and/or their representatives are consulted about their care needs and these needs are met in a sensitive way. EVIDENCE: The care records of four residents were looked at. The care plans set out how health, personal and social care needs would be met. The care plans showed that residents and/or their representatives are consulted about what their care needs are and how these will be met and the plans seen had been reviewed monthly. The home is working on developing a new format for care plans with the aim of making the plans easier for staff and residents to use. Risk assessments for falls and pressure sores were done and care plans were in place to set how what action would be taken in response to an identified risk. The required equipment to reduce the risk of pressure sores was in use but in some cases this was not clearly identified in the relevant care plans. One of the nurses has recently attended training on the prevention and treatment of pressure sores and is in the process of implementing the new guidelines provided by the Tissue Viability Nurse. Nutritional assessments were not available in the records seen. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 10 The plans showed that residents have access to a range of health and social care staff including General Practitioners, community psychiatric nurses and palliative care nurses. A chiropodist visits the home and eye care and dental care are arranged as needed. The manager is planning to implement the Liverpool care pathway, this is a model of good practice for palliative care, and all the nursing staff are currently having training on this subject. Medicines are stored safely, the required records and policies and procedures are in place, and arrangements have been made for the safe disposal of medicines to comply with recent changes to the law. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 standard(s) 12, 13, 14 & 15 People living in the home are encouraged to take part in social and leisure activities, to keep in contact with their friends and family and to exercise choice and control over their lives. EVIDENCE: Daily routines are flexible and it was clear from conversations with residents and from what was seen during the visit that residents could choose how and where to spend their time. In the bedrooms seen residents had their personal belongings around them. On the day of the inspection the home was busy, the chiropodist and hairdresser were visiting and in the afternoon several residents went to the lounge to listen to an entertainer singing “Songs from the Fifties”. Residents are regularly consulted about the planned programme of activities and the newsletter for July and August has details of all the things that will be going on in the home over the summer months. The planned menus for July and August are circulated with the newsletter. Residents said they enjoyed the food and are able to choose what they want to eat. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 12 People from the local Roman Catholic and Church of England churches visit the home and residents are offered the opportunity to take part in Holy Communion services. Residents and their representatives are given written information about the arrangements for visiting and residents can see their visitors in private. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 standard(s) 16 & 18 Residents are protected and feel safe living in the home. Residents are aware of how to raise any concerns they might have. EVIDENCE: The complaints procedure is made available to residents and their representatives, residents said they knew whom to speak to if they were concerned about anything and they felt they would be listened to. The home has not had any complaints since the last inspection. A copy of the local authority adult protection procedure is available in the home; all staff are booked to attend external training on abuse and adult protection later in the year. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 standard(s) These standards were not inspected EVIDENCE: Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Well-trained and competent staff meet residents’ needs. Residents are protected by good recruitment procedures. EVIDENCE: Duty rosters were available for all staff. The manager reviews staffing levels to make sure there are enough staff to meet residents needs. Residents said the staff were “very good” and did not express any concerns about the numbers of staff available. The files of two recently appointed staff members were looked at and showed that robust recruitment procedures are followed. The files showed that new staff are given a detailed induction. There is good programme of staff training and records were seen which provided details of the qualifications held by staff and the training they had done. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 38 The home is well managed and the manager is well able to discharge her responsibilities. She offers good leadership to the staff and makes sure that that residents are protected and cared for in a proper manner. EVIDENCE: The home issues questionnaires every year to residents and their representatives, the manager is now working on this year’s questionnaire, which will look at the delivery of care and residents views of the quality of life they experience in the home. The home has regular residents meetings and the care records seen showed that residents and their representatives are consulted. The home does not collect pensions for any residents; they do hold some personal money and records of all transactions are kept manually and on computer. Receipts are available for most purchases; to safeguard those dealing with cash such transactions should be witnessed. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 17 All accidents are recorded; accidents are reviewed at regular health and safety meetings and whenever possible action is taken to reduce the risk of similar incidents happening again. To comply with Data Protection law records of accident should be kept with each persons care records. The home has well established systems for making sure that all the necessary maintenance checks are done and recorded. Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 17(1)(a) Schedule 3. 3(m) 12 Requirement The care plans must provide details of the type of pressure relieving equipment that is in use. The programme of fitting door locks to service users bedrooms must continue. Previously agreed timescale 30 December 2005 Timescale for action 21 October 2005 30 December 2005 2. 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. 1. 2. 3. 4. 5. Refer to Standard 3 7 8 35 38 Good Practice Recommendations The records of the pre-admission assessment should state clearly when and where the assessment was done and who was involved. It is recommended that the current system for reviewing care plans be reviewed. Nutritional assessments should be done for all service users. Two signatures should be recorded for all cash transactions. To comply with the Data Protection Act accident records should be filed in individuals records. J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 20 Wellington House Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 Page 21 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 © 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 Wellington House J52 J03 S19860 Wellington House V240556 270705 Stage 2.doc Version 1.40 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!