Inspection on 11/10/05 for Welshwood Manor

This inspection was carried out on 11th October 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

Welshwood Manor 02/02/07

Welshwood Manor 30/01/06

Welshwood Manor 27/01/05

Welshwood Manor 26/05/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOMES FOR OLDER PEOPLE Welshwood Manor 37 Welshwood Park Road Colchester Essex CO4 3HZ Lead Inspector Diana Green Unannounced Inspection 11th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 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. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Welshwood Manor Address 37 Welshwood Park Road Colchester Essex CO4 3HZ 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) 01206 868483 01206 870615 Davard Care Homes Limited Mr Robin Neal Pickering Care Home 32 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (2), Old age, not falling within of places any other category (19), Physical disability (3), Physical disability over 65 years of age (32) Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 55 years and over, who require nursing care by reason of a physical disability (not to exceed 3 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 32 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 19 persons) One person, under the age of 65 years, who requires care by reason of a physical disability and who also has a learning disability, whose name was made known to the Commission in May 2004 One service user, aged 90 years and over, who requires nursing care by reason of a physical disability who also has a learning disability, whose name was made known to the Commission in January 2005 One service user, aged 65 years and over, who requires nursing care by reason of a physical disability who also has a learning disability, whose name was made known to the Commission in January 2005 The total number of service users accommodated in the home must not exceed 32 persons 26th May 2005 5. 6. 7. Date of last inspection Brief Description of the Service: Welshwood Manor provides nursing and personal care with accommodation for up to 32 older people and 3 younger adults with a physical disability. Welshwood Manor is owned by a private organisation named Davard Care Homes Ltd. The home is located at the end of Welshwood Park Road, a quiet cul-de-sac to the north of Colchester and a short drive from the town centre. The home was opened in 1999 and comprises a three-storey property that has been extended to provide additional accommodation. Further upgrading of the premises has been completed recently to provide increased single en-suite accommodation and an additional communal room. There are 26 single en-suite bedrooms and 3 double bedrooms. There is a passenger lift. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 5 The home has a garden overlooking open fields to the rear that is laid to lawn and shrubs with an arbour and patio garden with seating that is accessible to wheelchair users. Welshwood is accessible by road and rail and the nearest station is in Colchester. Parking is available in the small car park and adjacent road. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 11/10/05, lasting 7 hours. The inspection process included: discussions with the registered manager, activities coordinator, the cook, the laundry assistant, five staff, the maintenance person, five residents, two relatives and feedback from health and social care professionals; a partial tour of the premises including observation of three bathrooms, the sluices, communal areas and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Nineteen standards were covered, and three requirements including one second repeat requirement and four recommendations made. The inspection found that action had been taken promptly to address the remainder of the previous requirements and recommendations. It was evident that Welshwood Manor Nursing and Residential Home aims to provide and is successful in achieving a high standard of personal and nursing care for residents. The registered manager and staff were welcoming and helpful throughout the inspection. What the service does well: Welshwood Manor provides a high standard of nursing and personal care for residents. The atmosphere is warm and friendly resulting in a very homely environment for residents. The manager, deputy and staff strive to develop best practice. Staff are well supervised and there is good staff support and development resulting in a well-motivated team. Residents and relatives were unanimous in their praise of the manager, deputy manager and staff. One resident said “this place is very nice”, I’m happy with everything”, “ staff are very good, including Paula and Robin”. Another resident said “the staff are very nice, they treat me with respect”, “I feel safe here”. Relatives spoken with said that communication was good and the manager kept them well informed. One relative said they gave the manager “top marks”. Residents’ health and personal care needs are met appropriately and well monitored and prompt referrals are made to GP’s and relevant health professionals where required. Care plans are regularly reviewed in consultation with residents and their relatives and risks closely monitored. A commitment is made to involving residents and their relatives and to respecting individual choices. Welshwood Manor has a sound staff training and development programme and has Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 7 exceeded the standard for NVQ training with 67 of staff having NVQ level 2 or 3. What has improved since the last inspection? What they could do better: Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 8 Assessments could be improved to ensure that religious needs are documented and risk assessments are undertaken for residents at risk of falls. Activities records should be recorded consistently to demonstrate the outcome for residents as those spoken with were clearly motivated by their involvement. The review of care plans needs to be evidenced by an updated or new care plan where needs have changed and residents’ agreement could be confirmed by signature. The standard of cleaning of the kitchen must be improved. The kitchen requires upgrading and refurbishment and an action plan should be forwarded to the commission setting out how this is to be achieved. 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. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 9 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 Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 The service operates a thorough and responsible pre-admission assessment process: care and attention is given ensuring that the home can meet the individual’s needs, resulting in appropriate admissions. This home does not provide intermediate care. EVIDENCE: From discussion with the manager and feedback from residents there was evidence that the manager or deputy manager, both registered nurses, assessed all prospective residents either at home or hospital wherever possible. Four care files were inspected. Copies of care management assessments were held on file where relevant. Assessments covered most care needs but some details were brief. Social interests, hobbies and cultural needs were recorded. However there was no risk assessment for falls and no record made of religious needs, although it was evident religious needs were being met and risks were monitored. The manager and staff demonstrated a good understanding of residents’ needs. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 11 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 The care planning processes are clear and consistent and provide staff with the necessary information to satisfactorily meet residents’ needs. Residents health and personal care needs are consistently well met within the home. Staff treated residents with dignity and respect. EVIDENCE: Four care files were inspected. All four contained care plans that covered all key needs (physical and social) and provided good detail of the action required of staff to meet residents’ needs. Care plans had been reviewed monthly and confirmed by signature. There was evidence from discussion with residents and relatives that they were kept fully informed on the plan of care but this was not confirmed by signature on any of those sampled. Assessments for moving and handling/mobility, pressure areas, continence needs and risk assessments for bed rails were recorded in the files inspected and had been regularly reviewed. Residents spoken with said staff were very good and felt that staff cared for them appropriately and gave them assistance, as they required. Staff were observed to professional, polite and respectful towards residents Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 12 and to address them by their preferred name. Positive feedback was received from health and social care professionals who said they found the home provided a good standard of care. All residents appeared well cared for and relatives spoken with said they confidant in the manager and deputy and in the standard of care provided by care staff. Records showed good monitoring and provision of health care needs with appropriate and prompt referrals to GP’s and health and social care professionals. The home had a GP who attended weekly to review residents’ needs and on request. Care staff were observed to speak sensitively and respectfully to residents. Residents spoken with said that staff respected their privacy and dignity, looked after them well and always addressed them by their preferred name. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 Daily routines are flexible, and there is a strong ethos in the home of promoting residents’ independence and choices. A good and appropriate range of therapeutic and social activities takes place in the home. The home supplies sufficient quantity and quality of food, and provides a well balanced diet that meets individual needs and choices. EVIDENCE: From observation and discussion with the manager and staff there was evidence that routines in the home were flexible and residents’ individual choices were accommodated. One resident had chosen to stay in their room not get dressed following their morning bath as they were not feeling well, another resident said they usually took part in activities but had chosen not to today, preferring to stay in the conservatory and listen to music. The home has a full time activities coordinator who has been in post for less than one year. Activities organised were based on a range of craft, quizzes and individual activities. According to their ability, residents were observed working with crayons, paints and other materials to develop collages and models in preparation for a planned exhibition entitled ‘Birds of the Rain Forest’. Care staff were also involved in assisting all those who wished and were able to take part. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 14 All residents spoken with said there were plenty to eat and drink. Most residents said they liked the food, but other comments were “the food is alright, but sometimes I don’t like it” and “it isn’t home cooking”. The main meal on the day of the inspection was well balanced, looked appetising, and was eaten well by residents; nutrition records showed a good range of meals being provided and good monitoring of nutritional intake. Staff were observed to assist residents in an appropriate and respectful way during their lunch, and the dining room was pleasantly laid out. Residents said they were encouraged to eat in the dining room but could also choose to eat in their room. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The complaints procedures and practices at Welshwood Manor assure residents and their relatives their concerns will be listened to and acted upon. EVIDENCE: The home had a complaints procedure that included timescales within which complainants can expect a response and their right to complain directly to the CSCI at any stage. No complaints had been received by the home or the CSCI since the last inspection. The procedure was included in the statement of purpose and displayed in the home for resident and representatives’ information. Feedback from residents was unanimous in their praise for the manager, the standard of care and staff at the home. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 16 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, 22, 25 & 26 Welshwood Manor provides a homely and comfortable environment for residents. Recent upgrading and refurbishment of some rooms has enhanced the décor. Attention is now needed to upgrade the kitchen to prevent potential health and safety risks developing. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the sluice and the laundry. The home was in a good state of maintenance and decoration. There was a programme of regular maintenance in place. Communal rooms were clean and well decorated and furnished to provide a homely environment for residents. Residents spoken with said their rooms were always kept clean. The gardens were attractive and well maintained and provided a pleasant outlook with good access for residents. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 17 The home had one passenger lift that records confirmed was regularly maintained. Grab rails had not yet been fitted due to problems with the contractors. The premises were wheelchair accessible throughout. Hoists and assisted baths were well maintained. Call systems were provided in resident’s rooms, however one resident with reduced mobility had no call bell accessible to them in their room. The heating, lighting, water supply and ventilation met the relevant environmental requirements as evidenced from the home’s records. Checks to minimise the risks from legionella were undertaken annually and confirmed from the records. Rooms were centrally heated with controls in individual rooms and radiators were guarded as part of a risk assessment. Residents’ rooms, communal rooms and bathrooms were clean and hygienic throughout with no odorous smells but some sinks and baths would benefit from descaling. However the standard of cleaning in the kitchen was inadequate. Washbasins, lighting and some equipment had not been adequately cleaned and the dishwasher needed to be descaled. Equipment was old and need of replacement and the cooker hob was rusty. Hand-washing facilities (liquid soap and paper towels) were available for staff throughout the home and infection control practices were observed to be safe. The home had two sluice disinfectors, one on each floor of the premises that were well maintained. The laundry was small but equipped as required and well organised. Laundry and sluice facilities were located away from areas where food was prepared or eaten. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 18 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 & 29. Staffing levels and skills are appropriate to meet the personal care and physical needs of service users. Staff morale is high resulting in an enthusiastic and well-trained workforce who work positively to improve residents ‘quality of life. The recruitment processes are robust to ensure the protection of service users. EVIDENCE: There were 29 residents at the home. The duty rota was inspected and complied with the levels previously agreed. From observation and discussion with the manager, staff and residents there was evidence that staffing levels were sufficient to enable personal care needs to be appropriately met. Residents spoken with said that that they were not kept waiting for long when they called staff. The home had an NVQ training programme in place. Two care staff were undertaking NVQ level 2 and 67 of staff had achieved NVQ level 2 or 3. The records confirmed that new care staff were registered on the TOPPS induction programme. The personal files of two new staff were inspected and confirmed the appropriate checks had been undertaken prior to appointment. Two satisfactory written references, proof of identity/copy of birth certificate and passports were available. The manager agreed to ensure photographs were taken where passports did not include a recent photograph. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 19 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 & 38 The manager has a clear development plan and vision for the home that he has effectively communicated to residents, staff and relatives. Health and safety systems and practices are promoted and upheld to ensure the safety of residents and staff. EVIDENCE: The registered manager of the home is an experienced registered nurse and qualified nurse tutor with several years of management experience at the home and previous experience in managing care homes. A deputy manager who was not on duty at the inspection supports the manager. Residents and relatives spoke highly of both the manager and deputy manager and said they felt supported by them. There was evidence of recent updated training having been undertaken and a planned programme of management development had been agreed for the deputy manager. The home was well managed and run in the best interests of service users. The management approach was open and Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 20 transparent and there was close consultation evident with staff and residents through regular meetings and discussion. One resident said the manager frequently assisted with their care and they found both him and his deputy very approachable. Staff said they respected the manager and looked to him for support. The home had a health and safety policy statement and there was evidence from the records and in discussion with the manager and staff that safe working practices were in place. All accidents, injuries and incidents were wellrecorded and appropriate action taken. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X 2 X X 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X 3 Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 22 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 OP22 Regulation 13(4) Requirement The registered person must ensure that grab rails are fitted in the corridors of the home. This is a second repeat requirement The registered person must ensure that call bells are within reach of residents at all times. The registered person must ensure that the kitchen is adequately cleaned. Timescale for action 30/11/05 2 3 OP22 OP26 13(4) 13(3) 14/11/05 14/11/05 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 Refer to Standard OP3 OP7 OP26 Good Practice Recommendations The registered person should ensure residents’ assessments include religious needs and a risk assessment for falls. The registered person should ensure care plans are agreed with residents and confirmed by signature where possible. The registered person should ensure that washbasins, baths and the dishwasher are regularly descaled. DS0000015344.V258307.R01.S.doc Version 5.0 Page 23 Welshwood Manor 4 OP19 The registered person should ensure that an action plan with timescales for refurbishment of the kitchen is forwarded to the commission. Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Welshwood Manor DS0000015344.V258307.R01.S.doc Version 5.0 Page 25 - 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. 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