Inspection on 18/08/05 for Wellington Lodge

This inspection was carried out on 18th August 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

Wellington Lodge 14/02/07

Wellington Lodge 03/02/06

Wellington Lodge 15/03/05

Wellington Lodge 31/01/05

Wellington Lodge 12/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Wellington Lodge 334a Waterloo Road Cheetham Manchester M8 0AX Lead Inspector Sue Jennings Unannounced 18 August 2005 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 Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wellington Lodge Address 334a Waterloo Road Cheetham manchester M8 0AX 0161 740 8549 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) Anchor Trust Responsible Individual Mrs Jane Rachel Ashcroft Margaret Mary Catterson CRH Care home PC Care home only 32 Old age 25 Sensory Impairmant over 65 7 Category(ies) of OP registration, with number SI(E) of places Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The maximum number of service users requiring personal care only by reason of old age shall be 32. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home may accommodate seven named service users with sensory impairment who are also over sixty five years of age should any of these service users no longer require the accommodation provided at the home the places will revert to the category old age (OP). Date of last inspection 15 March 2005 Brief Description of the Service: Wellington Lodge is a purpose built home, owned and managed by Anchor Trust. The home offers 24-hour personal care and accommodation is provided in single bedrooms with en suite facilities. The building is situated on extensive landscaped grounds with ample car parking provision to the rear of the building. The home is located in the Cheetham Hill area of Manchester, within 2 miles of the city centre and in close proximity to local shops, facilities and bus routes. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection, which took place over the course of 4.5 hours on Thursday 18th August 2005. During the course of the inspection time was spent talking to the registered manager, residents and staff members to find out their views of the home. Time was spent examining records, documents, residents and staff files. A tour of the building was also conducted. During this inspection it was noted that the majority of requirements from the previous inspection had been addressed and there was evidence that this home was working hard to achieve a good outcome for the residents. 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. There have been no complaints received by the home or the Commission for Social Care Inspection since the last inspection. What the service does well: Where possible, prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. One resident said “my husband and I came to look around the home we were given a cup of tea and were able to sit in the lounge for a while talking to other residents”. All residents were reviewed after 6 weeks as a matter of course. The review meeting consisted of the resident, relatives, the registered manager and the Care Manager before a decision regarding permanent residency was made. One resident spoken to said “my son visits me whenever he wants to, there are no rules”. A number of residents were spoken to after lunch and one said “ the food is lovely we have plenty to eat, too much sometimes”. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 6 There had been no complaints since the last inspection. The manager kept a log of all complaints received this included the detail of the complaint, the investigation and subsequent outcomes. 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 Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.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 Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.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) 3, 4 and 6 The home carries out an assessment of prospective residents care needs prior to their admission they and their relatives/friends are able to visit the home before making the decision to stay. EVIDENCE: The home had developed a pre-admission assessment form, to ensure prospective residents are only admitted to the home if their needs can be met. The prospective resident, his/her representatives and any relevant professionals were involved in the assessment process and in developing a care plan. The registered manager or a senior care officer would visit the prospective resident in his/her own environment or in hospital to carry out the preadmission assessment. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 9 There were a number of residents with hearing impairment accommodated at the home. There was evidence to show that the manager was attempting to secure some basic training in BSL (British Sign Language) for staff but with little success. The manager reported that she wanted staff to be able to communicate effectively with residents to ensure resident’s needs were being identified and met. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 The home had continued to make progress in improving the care planning process and the arrangements to ensure that the health and personal care needs of the residents are identified and met. However there were a number of concerns expressed about recording systems. EVIDENCE: Each resident had an individual ‘lifestyle agreement’ (care plan) that had been developed using information from the Care Management Assessment and the pre-admission assessment carried out by the manager of the home. A random sample of care plans was examined and found to lack the detailed information required by staff to enable them to meet resident’s needs. The recording in the daily diary sheets did not reflect the care delivered over a 24-hour period with some entries stating ‘fine today down for meals’. The daily records must detail the action taken by staff to meet the individual’s needs. The manager reported that they were in the process of developing the care plans further and there was evidence of a planned workshop to discuss recording. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 11 Risk assessments were observed to be included within the individual plan of care. Each resident was registered with a local General Practitioner (GP) where possible residents had retained their own GP. Residents could see their GP in the privacy of their own room. There was evidence to show that residents had been referred to other specialised services according to residents assessed needs. This included District Nurses, The Early Dementia Intervention Team, Dentist, Dietician and Chiropodists. Residents spoken to said that staff treated them with respect and dignity and that when being given personal care dignity was maintained. One resident said they were made to feel comfortable when staff assisted them to have a bath. The home used the NOMAD monitored dosage system. The Medication Administration Record sheets (MAR) were up to date with no gaps in recording. There were a number of items dispensed in an inner and outer container that were only labelled on the outer box. To avoid misadministration the label must be affixed to the item itself. The home had not been recording the temperature of the medication fridge to ensure medication is stored at the appropriate temperature the fridge temperatures must be recorded on a daily basis. There is a risk that medication, which is not stored at the appropriate temperature, may not be effective. The home had a policy on Bereavement and residents were able to discuss their preferences during the care planning process. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Residents were able to maintain contact with family and friends and were able to exercise choice and control over their lives. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. The home provided a comfortable environment for the residents who live there with some activities available. EVIDENCE: The manager reported that residents did not want a structured activity programme, however, a poster was displayed on the notice board in the entrance hall advertising a range of activities. Residents could choose if they wanted to participate in any of the activities. It was reported that residents enjoyed trips out into the local community in small groups this was arranged on a regular basis. The home had a visiting policy and residents were able to have visitors at any time. Residents were able to see visitors in the privacy of their own room. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 13 The home did not place any restrictions on visiting at any reasonable time. The home’s policy on visiting was available in the Service Users Guide and also in the terms and conditions. One resident spoken to said “visitors were welcomed into the home” and that they were able to see them in the privacy of their own room. Residents were encouraged to bring personal possessions into the home, and this was evidenced during a tour of the building. One resident said “ I brought some photographs and a few ornaments”. The home’s menu was based on a 4-week rota and a menu was displayed in the main hallway. The menu indicated that the home provided a nutritionally balanced diet offering choice. A number of residents spoken to said that the meals were “very good” and there is always plenty to eat”. One resident said that “there is a choice of hot meals every day”. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had a complaints procedure that was known to residents and they knew how to make a complaint The home’s policies and procedures served to protect the residents from abuse. EVIDENCE: The home had a complaint policy, which was provided to all residents on admission and residents were aware of how to make a compliant. Residents spoken to appeared to be aware that there was a procedure for making a complaint. One resident spoken to said “I have nothing to grumble about, some do but they can’t please everyone” another said “if I did have a complaint I would speak to the manager or my family”. Another resident said “there is nothing to complain about the staff are lovely and the food is good”. Other residents spoken to said that they would not worried about making a complaint. The home had a policy and procedure for the protection of vulnerable adults in line with the Manchester Multi Agency Policy for the Protection of Vulnerable Adults (POVA) and the Department of Health No Secrets guidance. Staff spoken to had an understanding of issues surrounding abuse and appeared to have some awareness of the local adult protection procedures. The manager reported that she had held a number of in-house workshops in relation to Adult Protection issues. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 15 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) 19 and 26 The premises are safe and the home’s environment including the standard of hygiene was well maintained both internally and externally. EVIDENCE: The home felt comfortable and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature and of an adequate standard. The manager reported that the communal areas had been redecorated and that carpets in the corridors had been renewed. Access to all floors was via a passenger lift and stairwells. Grab rails were fitted throughout the home and a variety of electrical hoists were available. Appropriate aids were fitted i.e. assisted baths, handrails and raised toilet seats for residents who required assistance. Privacy locks were fitted to bathroom and toilet doors and an emergency call system was available. The need for any other aids would form part of the assessment carried out prior to Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 16 admission. Each bedroom had a letterbox to enable residents to receive their mail unopened. The home has secure well-maintained grounds with a variety of garden areas, which are accessible to residents in wheel chairs. Residents living on the ground floor had the choice of having window shutters fitted to provide additional security. At the time of the inspection the home was clean and free from unpleasant odours. The laundry facilities were located away from food storage, preparation areas and the laundry floor was impermeable and easily cleaned. All washing machines had the appropriate programmes to ensure that laundry was cleaned at the correct temperatures to reduce the risk of infection. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 17 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 and 29 The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. EVIDENCE: At the time of the inspection the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. The numbers of staff on duty were in line with the minimum requirements of the previous registering authority. A random sample of staff files was examined and found to contain two written references, a Criminal Records Bureau check, where staff had been employed after 26th July 2004 they had been checked against the Protection Of Vulnerable Adults list therefore ensuring that people employed at the home are safe to work with Vulnerable people. Each member of staff had an individual training and development file, which also included certificates of achievement. Staff members spoken to confirmed that they had regular training sessions relating to the care of older people. At the time of the inspection it was reported that eight members of staff were working towards NVQ Level II, two members of staff had achieved NVQ Level II and two members of staff had achieved NVQ Level III. All of the senior care staff and the manager had unit A1 NVQ assessors award and were able to act as internal assessors for staff undertaking NVQ training. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 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 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) 35 and 38 Overall the home had systems and procedures in place, which promote the health, safety and welfare of the residents and staff. EVIDENCE: The manager reported that resident’s money was still held in one account named ‘Service user accounts’. At the last inspection a requirement was made that individual bank accounts are maintained was made. This matter has not been addressed and the requirement made at the last inspection has been reiterated in this report. This standard will be fully assessed during the next inspection. Hazardous substances were stored in line with the Controls of Substances Hazardous to Health (COSHH) guidance to ensure that there were no risks to residents. There was evidence to show that the fixed electrical and gas appliances had been serviced at regular intervals. Regular fire drills were held rotating the Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 19 test area. A portable appliance test had been undertaken. The passenger lift and hoists were serviced on a regular contract. A contract was in place for the appropriate disposal of clinical waste. A member of staff spoken to demonstrated a good understanding of what action was required in the event of a fire, none of the fire exits were blocked and there was evidence to show that these areas were checked on a daily basis both of which reduced the risks to residents. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x 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 x x 2 x x 3 Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 21 NO 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 7 Regulation 15 Requirement The recording in the daily diary sheets must be more detailed and reflect the care delivered over a 24 hour period. Timescale for action 30.9.05 2. 7 15 Care Plans must include specific 30.9.05 details of the care needs and the required intervention to meet the identified care need. (Previous timescale of 1.4.05 not met) The home must record the temperature of the medication fridge on a daily basis. 30.9.05 3. 9 13 4. 9 13 Medicines dispensed in an inner 30.9.05 container and an outer box must be labelled on the item as well as or instead of the outer box. The home must ensure that money belonging to residents is held in an account in the name of the resident. (Previous timescale of 1.5.05 not met) 30.10.05 5. 35 20 Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 22 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. Refer to Standard 27 Good Practice Recommendations It is strongly recommended that the actual hours worked by staff is entered onto the staff rota. Wellington Lodge F55 F05 s21590 wellington lodge v243478 180805 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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. 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