Inspection on 30/01/06 for Welshwood Manor

This inspection was carried out on 30th January 2006.

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 11/10/05

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 30th January 2006 01:00 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.V281930.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 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 (4), Physical disability over 65 years of age (32) Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 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 4 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 11th October 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 4 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.V281930.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 30/01/06, lasting 2.5 hours. The inspection process included: discussions with the deputy manager, proprietor, activities coordinator, the cook, two staff, seven residents; 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). The deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 6 Arrangements have been made to ensure call bells are within reach of residents. The standard of cleaning has improved with attention to detail. The kitchen has been cleaned and decorated and a new dishwasher installed. A trolley has been purchased to improve the storage of care plans. Developments in care planning continue and this has included improved assessment and monitoring of wounds using measurement grids for accuracy. 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. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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: Three care plans were sampled. The manager or deputy manager, both registered nurses undertook residents’ assessments either at home or hospital where possible. Copies of care management assessments were held on file where relevant. Assessments covered all care needs as detailed under this standard. Social interests, hobbies and cultural needs were recorded. Risk assessment for falls had been undertaken in two of those sampled. This home does not provide intermediate care. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 The care planning process provides good information for care staff to satisfactorily meet residents’ needs with the agreement of residents and/or their representatives. The systems for the administration of medicines are good with clear and comprehensive arrangements being in place but some attention is needed to ensure records are made strictly in accordance with requirements. EVIDENCE: Three care files were inspected. These contained care plans that covered the key needs (physical and social) as detailed under this standard. All three care plans had been regularly reviewed. Residents spoken with were aware of their care plan, however none had the residents/or representative signature to confirm their agreement. Assessments for moving and handling/mobility, risk of falls, pressure areas and continence needs were recorded in all of the files inspected. Measurement grids had been introduced as a more accurate method of monitoring progress made in wound care. Care plans were contained good details of the action required to meet residents’ needs and were regularly reviewed. Daily records were well recorded with evidence of close monitoring of residents needs and action taken as required. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 10 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. Residents spoken with said that their personal care needs were met satisfactorily. The home had a medicines policy and procedures and up to date guidance available for information. The providing pharmacist was available for advice and support. Medication was stored in a store cupboard on the first floor of the home. Temperature monitoring of storage facilities was in place. Records of administration were generally well recorded. However one prescribed cream was not confirmed in the MAR (medicines administration record) record on application. The address from which controlled drugs were received was insufficiently detailed. Advice was given to ensure the name and address of destination is recorded when controlled drugs are removed from the premises. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 Visiting arrangements are open and relaxed; staff encouraged contact with the local community. EVIDENCE: Residents spoken with said their relatives and friends were able to visit at anytime and said that staff were very friendly always offered a drink. A separate visitors room was available for them to meet in private. Relatives said they found the manager and staff friendly and supportive and communication was very good. The statement of purpose and service users’ guide detailed the home’s policy on visiting arrangements and record of activities confirmed that links were made with the local community. A regular communion service was held at the home and school groups attended the home at Christmas for carol singing and other activities. Some residents also attended a stroke club that was held locally. Residents said they were given a choice in time of getting up, in where and when to eat and in taking part in activities. All residents had a representative or advocate to act on their behalf. Information on advocacy services was displayed for their information and arranged as needed. The service user guide detailed residents’ rights to access their personal care records in accordance with the Data Protection Act 1998. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. EVIDENCE: The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy and this was under review to reflect local Essex procedures. All staff had received copies of the revised local Essex multiagency guidance. The records provided evidence that staff had received training in POVA (protection of vulnerable adults). The manager and deputy manager were booked to attend teaching course arranged by the Essex Vulnerable Adults Committee. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Welshwood Manor was safe, well maintained and had a homely environment; residents rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic with safe infection control practices evident. EVIDENCE: A partial inspection of the premises was made that included communal rooms, three bathrooms, a number of residents’ rooms, the kitchen and the laundry. The home was in a good state of maintenance and decoration. Communal rooms were clean and well decorated and furnished to provide a homely environment for residents. The quality audit confirmed that residents found the standard of cleanliness satisfactory. The gardens were 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. Standard 22 was not fully inspected although from observation and previous knowledge of the home it was evident that appropriate aids and equipment Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 14 were provided. Grab rails had not yet been fitted due to problems with the contractors that were expected to be imminently resolved. The home was clean and hygienic throughout with no malodorous smells. Safe practices in infection control were evident. The laundry was well organised and linen inspected was well laundered. The kitchen had been thoroughly cleaned and redecorated since the previous inspection and a new dishwasher installed. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 Staff morale is high resulting in an enthusiastic and stable workforce that works positively with residents to improve their whole quality of life. EVIDENCE: There were 28 residents at the home. Staffing levels were appropriate to meet the needs of residents and were confirmed at 1 registered nurse and 4 care assistants. The deputy manager, administrator, proprietor, laundry assistant, cook, kitchen assistant, 2 domestic staff and activities coordinator were also on duty. The home maintained a staff rota confirming the number of staff on duty and the capacity in which they work. The staff records confirmed that no one under the age of eighteen was employed to provide personal care. The home had a planned training programme in place. From discussion with the deputy manager there was evidence of recent updated training provided. This was also confirmed from a copy of the training plan/records subsequently provided. This showed that up-to-date training in fire safety and moving and handling had been provided but not all staff had attended. The deputy manager had also undertaken a medication update as part of a distancelearning programme. Updated training in wound care had also been provided internally. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 The manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The systems for service user consultation are good with substantial evidence that indicates their views are both sought and acted upon. The financial interests of residents are generally well protected by the systems but these are not always well adhered to. 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 and is supported by a deputy manager. There was evidence of recent updated training having been undertaken. The deputy manager was to undertake the registered managers’ award. The home was well managed and run in the best interests of service users. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 17 The manager was well supported by the proprietor who regularly visited the home. Twice yearly relatives’ meetings were held and residents’ questionnaires were distributed annually to obtain feedback on how the home was meeting their needs. An annual audit was also undertaken from which an annual plan was developed for the home. The quality survey for 2005-6 demonstrated an overall improvement in residents’ satisfaction in catering, social activities, accommodation and domestic services. The manager and deputy manager frequently provided personal care alongside staff and ensured standards of care were upheld. Service user’s monies were sampled. All residents had an advocate/representative to manager their finances on their behalf and there was evidence that this was monitored to ensure they received sufficient funds. Appropriate procedures were in place with receipts held for expenditure. However two minor discrepancies were found in two of those sampled. Other records were confirmed as correct. Standard 38 was not fully inspected. There was evidence from observation, records and previous knowledge of the home that indicated the manager aimed to ensure the health, safety and welfare of service users and staff. However not all staff had received training in manual handling and fire safety as required. Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 x 3 X X 2 Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that administration of prescribed creams is confirmed by signature on the MAR sheet. The registered person must ensure that the records of the receipt and disposal of Controlled Drugs made in the Controlled Drug Register carry the name and address of the supplier or recipient on disposal. The registered person must ensure that grab rails are fitted in the corridors of the home. This is a third repeat requirement. The registered person must ensure that all staff receive fire safety training as required. The registered person must ensure that all staff receive training in moving and handling as required. Timescale for action 28/02/06 2 OP9 13(2) 28/02/06 3 OP22 13(4) 30/04/06 4 5 OP38 OP38 23(4)(d) 13(5) & 18(1) 30/04/06 30/04/06 Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Welshwood Manor DS0000015344.V281930.R01.S.doc Version 5.1 Page 21 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. 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