Inspection on 26/07/05 for Wells Court

This inspection was carried out on 26th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Wells Court 10/06/08

Wells Court 29/10/07

Wells Court 21/03/07

Wells Court 13/03/06

Wells Court 02/02/05

Wells Court 15/09/04

Similar services:

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Fairfields Country Rest Home

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Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Wells Court Herbert Road Salcombe Devon TQ8 8HD Lead Inspector Margaret Crowley Announced 26 July 2005 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. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wells Court Address Herbert Road, Salcombe, Devon, TQ8 8HD 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) 01548 843484 01548 843484 Wells Court Limited vacancy Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24), Physical disability over 65 years of age (24) Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Age 55/65 Date of last inspection 02/02/05 Brief Description of the Service: Wells Court is a detached two storey property in the estuary town of Salcombe in the South Hams area of South Devon. It is part of the Court Group of care homes, and is registered to provide care for 24 older persons who may also have a physical disability and/or dementia Accommodation is provided in single en suite bedrooms. Communal rooms are spacious and are situated on the ground floor. There is a small garden at the front of the property,. There is a passenger lift ,chair lifts and appropriate aids and adaptations. The service users have access to the Court Group minibus for outings. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day on 26th July 2005. A tour of the premises took place, and records were inspected. Service users and one relative were spoken with and completed questionnaires were received from service users and relatives. Staff on duty were observed in the course of their daily duties and 4 care staff were spoken with. Discussions took place with Mrs Nikki Rogers, the Responsible Person’s representative and Mrs MaryEllen Hooper, Acting Manager. What the service does well: What has improved since the last inspection? What they could do better: Service users rooms identified would benefit from new floor covering and redecoration. All hot radiators and pipe work accessible by service users are not guarded to prevent the risk of service users sustaining a burn. Hot water provided to washbasins does not have the temperature controlled to prevent the risk of scalds. Please contact the provider for advice of actions taken in response to this Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wells Court D54-D07 S3852 Wells Court V224087 260705 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 Wells Court D54-D07 S3852 Wells Court V224087 260705 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) 1,3 Prospective service users are provided with information to assist them in choosing to live at Wells Court. The admission procedure ensures that service users needs are assessed and can be met EVIDENCE: Wells Court has a statement of purpose and a service user guide, which has been revised since the last inspection. When new service users are admitted their needs are assessed prior to admission. Evidence was seen of the assessments undertaken. The management should inform service users or their representative in writing that their assessed needs can be met. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.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 Service users have care plans, which are reviewed and enable their needs to be met. The systems for the administration of medication are satisfactory with arrangements in place to ensure that service users’ medication needs are met. EVIDENCE: Evidence was seen of risk assessments and care plans, and a review system. Daily records showed that any concerns are recorded and addressed. Service users spoken with said that they are well are cared for and confirmed that their needs are met by staff who are accessible and attentive. Wells Court maintains good working relationships with primary care staff and the community psychiatric service. The district nurse confirmed the quality of the care provided and the positive atmosphere within the home. There are clear policies and procedures for the administration and storage of medicines. Medication records were found to be satisfactory. Where a service user self- medicates this is subject to risk assessment, and the service user has appropriate storage for the medicines. Those staff who administer medicines have received accredited training. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 10 Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.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) 12,13,15 Wells Court provides a resource for local older people who require care. Service users contact with the local community is encouraged and visitors are welcomed. A balanced and varied selection of food is available that meets service users tastes and choices. EVIDENCE: Routines within the home are flexible to ensure that residents can choose how they spend their time. Activities are provided in the main lounge and service users enjoy musical entertainment. Some service users prefer to spend time in their own rooms enjoying their interests, but like informal time spent talking with staff. The manager and staff are attempting to encourage service users to be more involved in choosing activities. Many service users lived in Salcombe prior to their admission and have local connections. The manager is exploring ways of encouraging more involvement with the local community and a garden party is planned. There is an open visiting policy and it was confirmed that visitors are made welcome. There is a varied rotating menu. All service users spoken with praised the quality and quantity of the meals. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 12 Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.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 Service users can be confident that procedures are in place to enable them to complain and to protect them from abuse EVIDENCE: The complaints procedure is displayed so that it is accessible to service users. No complaints have been received since the last inspection. There is an adult protection policy and procedure which is accessible to staff. Staff receive in-house training in adult protection. It is recommended that the manager and senior care staff attend the multi agency adult protection training. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.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) 19,24,26 Service users are provided with accommodation that is comfortable, attractive and clean. EVIDENCE: Since the last inspection two attractive, new en suite rooms have been provided which are equipped to a good standard. Communal areas are comfortable and attractive. Better use could be made of the small lounge, which at the time of the inspection contained walking aids. There is a small garden at the front of the property with a seating area, but the garden is not secure for use by service users with dementia. Feedback indicated that service users would benefit from more opportunities to enjoy the garden. Most bedrooms have been personalised, although a very small minority of rooms would benefit from being more homely. Locks have not been fitted to service users rooms. A suitable lock is provided if requested, but locks are not provided as standard on admission. This is documented within the home’s statement of purpose. New floor covering should be provided in rooms 12 and 19. Some rooms identified would benefit from redecoration. Additional radiators have not yet been fitted in the upstairs corridor and the en suite facilities of bedroom 15, as recommended in the previous inspection. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 15 Discussions took place regarding improved signage for people with dementia. The home was found to be very clean on the day of the inspection. There is an infection control policy and procedure. The home has a laundry that is fitted with a washing machine capable of a disinfecting cycle. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 An adequate number of staff are employed to meet the care needs of the current service users. Staff are provided with training opportunities to enable them to develop their knowledge and skills in caring for service users. EVIDENCE: The management said that there are sufficient staff employed to meet service users needs by day and by night. There is one waking and one sleeping-in member of staff at nighttime. Staffing levels are kept under review dependent on the needs of the service users. Staff rotas were seen and evidenced minimal, but adequate staff on duty to meet the care needs of the current service users, several of whom have dementia. There is a good range of experience within the staff group. Several staff have worked at Wells Court for a number of years. Staff confirmed that they are encouraged to undertake training. They felt well supported by the management and said that new staff are provided with an induction to enable them to do their work 50 of the care staff hold NVQ 2 or above and other staff are undertaking the training. In the past year staff have received mandatory training in fire safety, manual handling and health and safety and food hygiene control. In addition some staff have received training in the safe handling of medicines and first aid training. However, there are insufficient staff with a current first aid certificate to provide adequate cover. Records were inspected of staff most recently employed. CRB disclosures were not yet available for 2 members of staff. The management was reminded that two written references must be obtained prior to employment and a system of Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 17 chaperoning by named persons until POVA checks and CRB disclosures were obtained. Wells Court D54-D07 S3852 Wells Court V224087 260705 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) 31,33,38 Following a period of uncertainty, service users and staff are benefiting from having from a new manager in post. Service users live in an environment where most health and safety standards are met and maintained, but there is a lack of protection from hot surfaces and unregulated hot water temperatures. EVIDENCE: Mrs Mary-Ellen Hooper was appointed acting manager in March 2005.She is the second acting manager of the Wells Court since the registered manager left. She holds NVQ 4 in care and is undertaking the Registered Managers Award. No application has yet been received by the Commission for Social Care Inspection to register her as the manager. Staff spoken with said that she was supportive and listened to their views. The management and staff team are working together to create a homely and open environment. Service users and their relatives value this. Monthly, quality audits are undertaken by the responsible individual’s representative to examine all aspects of the provision of the service to ensure that standards are maintained. Service users views are sought. Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 19 Most routine health and safety issues are managed satisfactorily within the home. It is recommended that all staff receive fire prevention training sixmonthly, and more frequently for staff on duty at nighttime. All store rooms labelled as fire doors that require to be locked, or containing hazardous materials, must be kept locked. Hot water to service users’ washbasins is not regulated to a safe temperature. All service users have been risk assessed and there are warning signs above the washbasins, but this may not be sufficient to protect service users who are mentally and physically frail from the risk of scalds. Not all radiators and hot surfaces accessible by service users are protected. Wells Court D54-D07 S3852 Wells Court V224087 260705 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 3 x 3 x x x 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 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 2 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 2 x 3 x x x x 2 Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 21 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 OP3 Regulation 14 Requirement New service users or their representative should be informed in writing that their assessed needs can be met. The Provider must ensure that all water outlets that service users have access to deliver water at safe temperatures. Timescale of 30/04/05 not met The registered provider must ensure that all pipe work and radiators to which service users have access are risk assessed and guarded, according to priority,or have low surface temperature services. The Proprietors must apply to register a manager for the home Service Users rooms identified should have new floor covering fitted All store rooms labelled as fire doors that require to be locked, or containing hazardous materials, must be kept locked Staff must receive training in First Aid. Timescale for action 26/09/05 2. OP38 13 26/11/05 3. OP38 13 26/11/05 4. 5. 6. OP31 OP24 OP38 9 13 13 26/09/05 26/09/05 26/07/05 7. OP38 13 26/09/05 Wells Court D54-D07 S3852 Wells Court V224087 260705 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. 2. 3. 4. Refer to Standard OP18 OP24 OP19 Good Practice Recommendations The manager and senior care staff should attend the multi agency adult protection training. Service Users rooms identified should be redecorated Radiators should be fitted in the upstairs corridor and in the en suite facilities of bedroom 15 Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Wells Court D54-D07 S3852 Wells Court V224087 260705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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