Care Home: Welbourn Hall Nursing Home

Similar services:

• Byars Care Home
• St Marys Nursing Home
• Bramble Lodge
• Parkmanor Residential Home
• Thornham Grove
• Hunter`s Lodge
• London Road Neurological and Specialist Care Unit
• Carlton Care Home

What the care home does well Residents are cared for in a friendly and homely environment by staff who are knowledgeable about their care needs and respect their choices. They interact well with the residents and respond to their needs in a respectful and Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 responsive manner. People told us that they were happy with the facilities provided and the way staff delivers their care. Comprehensive care plans have been developed which tell staff about people’s needs and preferences, as well as the staffs role in supporting them. What has improved since the last inspection? Care plans have been improved to include details about people’s social needs, likes and dislikes. Staff are recruited robustly so that residents are protected from unsuitable people being employed. As part of the development of the new unit staff have received training regarding supporting people with dementia. Some improvements to the environment were also noted. This includes the kitchen being refitted and being awarded a 5 star rating from the Environmental Health Officer. What the care home could do better: Records must demonstrate that a comprehensive assessment has taken place prior to people being admitted to the home. This will show that the home has assessed potential residents comprehensively to determine if their needs can be met. Some areas of the home need attention; this includes structural repairs, routine cleaning and the control of unpleasant odours. Although people told us that the provider visits the home regularly his monthly reports need to better reflect his findings. They must also be signed and dated and held at the home. This will show how he is monitoring the home and what is being done to address any shortfalls. Other areas that would benefit from some attention include the following. Menu options should be displayed better so that people can clearly see what options there are at each mealtime. The training plan should be reviewed to make sure that it includes all the specialist training needed to meet people’s needs, such as specific conditions affecting older people. All staff should receive training about the Mental Capacity Act and Deprivation of Liberties so that they are aware of their role in protecting people’s rights and choices. Key inspection report CARE HOMES FOR OLDER PEOPLE Welbourn Hall Nursing Home Hall Lane Welbourn Lincoln Lincolnshire LN5 0NN Lead Inspector Dawn Podmore Key Unannounced Inspection 20th August 2009 09:30 DS0000070035.V377310.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welbourn Hall Nursing Home Address Hall Lane Welbourn Lincoln Lincolnshire LN5 0NN 01400 272771 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) anne.ruttle@btconnect.com Nish Thakerar Manager post vacant Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following category: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 40. 28th August 2008 2. Date of last inspection Brief Description of the Service: Wellborn Hall Nursing Home is a privately owned care home for older people. The home has been converted and extended from a former Victorian house. It provides residents’ accommodation on two floors with a passenger lift giving access to the first floor. The home is situated in the small village of Wellborn, which has a village shop and is on a bus route between Lincoln and Grantham. It provides nursing and personal care. Since the last inspection they have developed part of the home to provide an 11 bedded unit to offer a specialist care for people with dementia. The home has large gardens around the exterior of the home, a small enclosed courtyard and a car park for staff and visitors At the time of the inspection the acting manager confirmed that the weekly fees ranged from £348 - £510 depending on the residents assessed needs. Additional charges are made for services such as hairdressing, chiropody and newspapers. Information about these costs as well as the day-to-day operation of the home, including a copy of the last inspection report, is available at the home. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This key inspection visit was unannounced and took any previous information held by C.Q.C about the home into account. Throughout this report the terms we and us refers to the care Quality Commission (CQC). Before the visit the provider had returned an Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans for improvement over the next twelve months. The main method of inspection used was called case tracking. This involved selecting a proportion of residents and tracking the care they received through the checking of records, discussions with them and the staff who care for them, and observation of care practices. A partial tour of the home was also conducted, which included looking at some bedrooms, communal areas and bathing and toilet facilities. Documentation was sampled and the care records of the three people being tracked were examined. We spoke with 8 residents and 5 members of staff. They shared their views about how the home operated on a day to day basis and the care and facilities provided. We are trying to improve the way that we engage with people who use the services we regulate so that we gain a real understanding of their views and experiences of social care services. During this inspection we used a method of working where an ‘expert by experience’ visited the home as part of the inspection to help us get a picture of what it is like to live in this service. The term ‘Experts by Experience’ used in this report describes people whose knowledge about social care services comes directly from using them. The expert talked to some residents and staff and looked round the home over a 3 hour period. On the day of the visit 19 people were living at the home, but 2 were in hospital. What the service does well: Residents are cared for in a friendly and homely environment by staff who are knowledgeable about their care needs and respect their choices. They interact well with the residents and respond to their needs in a respectful and Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 6 responsive manner. People told us that they were happy with the facilities provided and the way staff delivers their care. Comprehensive care plans have been developed which tell staff about people’s needs and preferences, as well as the staffs role in supporting them. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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 Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are at risk of not being fully met due to the shortfalls in some pre-admission records. EVIDENCE: There is a Statement of Purpose and the Service Users Guide to provide people with information about the home and how it intends to operate. These had been reviewed and amended as part of the registration of the dementia unit. We looked at the pre-admission assessment form for someone who had recently come to live at the home. Although an assessment had been completed it contained only basic information and did not fully identify their needs or potential risks associated with their care in sufficient detail. Therefore it was difficult to determine if their needs could be fully met at the home. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 9 However another file contained good information about the persons care needs and identified risks in detail. The acting manager agreed that the detail completed did not cover all the areas required, such as the person’s mental condition, and agreed to review the form. The AQAA said that people are encouraged to visit the home before making any decisions and trial stays can be arranged. The manager confirmed that the home does not provide intermediate care. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and care needs are being met by staff who understand them and deliver care how they wish it to be delivered. EVIDENCE: We looked at the care records of 3 people living at the home choosing people with different needs. Two files for people who had lived at the home for some time contained comprehensive information about what care and support they needed and how they preferred to have their care and support delivering. Assessments for potential risk areas, such as manual handling and pressure damage, had been carried out. This information had then been used to formulate care plans to guide staff as to how to minimise any identified risks. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 11 Records about events during each person’s day had been completed in good detail. Care plans and risk assessments had been reviewed at least every month to evaluate the planned care and make sure that it was still applicable. The third plan we looked at was for a new resident and the deputy manager was still formulating a full care plan. However the daily notes and assessment completed by the night nurse gave staff adequate information about her main care needs and potential risk areas. There is a system in place to assess people’s capacity to make decisions about their daily lives. If the assessment shows that they do not have the capacity to make certain decisions the home takes a multidisciplinary approach to making sure that peoples best interests are considered and recorded. Peoples health care was being monitored and they have access to outside health professionals, such as doctors and specialist nurses. Specialist equipment such as pressure relieving mattresses was also being used. Wound care was being recorded in very good detail with photographs and records mapping any progress or deterioration. Staff were seen speaking to people with respect and they demonstrated a good understanding of the people they supported. They also knew how each person preferred their care delivering, as well as how to maintain their privacy and dignity. The expert by experience reported ‘Having talked to as many people as possible, they seemed happy and cared for. The staff seemed very caring, this was nice to see’. One lady told her that the staff were good at helping and talking to her as she wasn’t able to go home to her husband and that this took her mind off these matters. The home has satisfactory policies and procedures concerning the receipt, storage, administration and disposal of medications. Records were well maintained and there was an internal system in place to audit medications on a regular basis. The last pharmacist report from 10/6/09 raised no issues. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to an activities programme that meets their needs and are enabled to maintain relationships of their choice. EVIDENCE: There is a programme of activities which is coordinated by 2 of the staff who have designated times each day to arrange suitable activities. Residents told the expert by experience that they enjoyed the activities offered. During the visit we saw some people playing bingo in one of the lounges with small prizes being awarded to the winners. Other activities that had recently taken place included, one to one sessions, singing, bingo, visits to the hairdresser, DVD afternoon, cooking and games. Forthcoming events were also advertised on the notice board, such as a clothing party, outside entertainers and a summer fair, planned for the following week. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 13 Although the new dementia unit was unoccupied various activity items had been prepared ready for the first admission. These included memory boxes e.g. gardening box and laundry box. The expert by experience commented, ‘Something I did like was that in many areas they have moment flowers; these are reminders saying “it only takes 30 seconds to hug/smile/cuddle/a kind word” etc. These were all in big print enabling people to see them easily, they also had good idea boxes with things to touch and feel and one of the staff had made aprons with buttons, ribbons etc. to be able to touch and feel. These are excellent ideas’. Each person had a plan that outlined what they liked to do socially. Although the plans on file were in some cases quite basic this was supported by excellent additional information. This included a life book and an activities folder in front of each persons file. These detailed people’s hobbies and interests and showed what people had been taking part in, as well as photographs and memories. Staff said that not many outings took place as few people wanted to go out. However they told us that some people liked to go for a walk round the village or to the shops while others went out with their families. People said that visitors were made welcome and that staff were always friendly and helpful. Lunch was served by the cook through the hatch from the kitchen directly into the dining area. The menu was written on a blackboard and pictures of the meals were displayed close by. The deputy told us that following consultation with the residents at some meals each table had their own teapot so they could help themselves or staff could assist them The menu displayed was limited as only one option was written on the board. However people told us that they were asked the day before what they would like and alternatives were offered. The expert by experience noted ‘The meal was served table to table and kept on a hot trolley to keep it warm. The tables were all neat and people seemed to eat the food and enjoy it’. She did however comment that the broccoli looked yellow and overcooked. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are protected by clear policies and procedures for handling complaints and allegations of abuse. EVIDENCE: The home has a complaints procedure, which is displayed in the home and included in the Service User Guide. We have received no complaints concerning the home since the last inspection and the AQAA indicated that neither has the home. However there was a system in place to record and monitor any issues raised. People said that they knew how to make a complaint and would be comfortable highlighting any issues. The home has procedures concerning the protection of vulnerable adults. The acting manager had made one alert to the safeguarding team over the last year. This had been appropriately addressed by the home and additional measures taken to make sure that people were safe. Staff demonstrated a satisfactory knowledge of what to do if they suspected abuse could be occurring. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable and homely environment, but some areas are in need of attention. EVIDENCE: Part of the home has been recently developed into a specialist unit catering for up to 11 people with dementia. No residents had been admitted to the unit at the time of our visit but we looked at the general environment and some of the bedrooms. The unit looked welcoming with divisional activities available in communal areas. Bedroom doors had been painted in different colours to help people find their way round more easily. Some rooms needed minor repairs to the décor, such as the removal of raw plugs used previously for shelving. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 16 Although in general the home was in a satisfactory state of repair there were some areas that needed attention. The owner said a repair to the roof was underway and the room below the leak was being prepared for redecoration. The wallpaper at the top of the main lounge was also watermarked from the leak. During the tour of the building one area had an unpleasant odour. Staff said that efforts to control the odour had been explored with no satisfactory outcome. Neither the manager or the domestic staff could say how often the corridor carpets were shampooed and outside one toilet the carpet was heavily stained. The owner said that he was intending to renew carpets when he could and that extra carpet tiles should be available to replace the stained ones. We also noted that the grids on radiators had not been cleaned and were sticky and dusty. There were no systems in place to record and monitor when areas had been cleaned. The kitchen had been refitted and now has 2 separate areas, one for storage and the other for cooking. Something had been spilt in one of the fridges and not cleaned up and the expert by experience noted that the other one looked dirty round the seal. The cook said that all areas were cleaned regularly and produced records of this taking place. The expert by experience also said, ‘Looking around Welbourne Hall, I found it needed a good clean radiators, carpets etc. I think that they are trying however’. The need for the owner and manager to have a system in place to monitor the environment of the home was discussed. Garden areas were satisfactorily maintained. The enclosed garden in the middle has a patio area offering a safe place for people to sit in fine weather. There is also a fountain and bird feeders to attract the wildlife. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a well trained staff team, and are protected by current recruitment procedures. EVIDENCE: People said that there was enough staff available to meet their needs. The staff we spoke to also confirmed that the current staffing levels were satisfactory. Staff supported people in a calm and relaxed manner and they had time to stop and talk to them. We checked the files of 2 new staff and these showed that their recruitment had been carried out correctly with essential checks, such as written references and C.R.B. (Criminal Records Bureau) checks, being undertaken. A new carer interviewed also confirmed that a robust procedure was in place. New staff received a satisfactory induction to the home. The home has a training programme which includes essential subjects such as safeguarding people from abuse, fire safety, dementia awareness and food hygiene. Two people had also attended the ‘improving the lives of people with dementia’ training facilitated by Lincoln County Council. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 18 The manager said that along with her deputy she was attending fire risk assessment as well as a two day course about health and safety risk assessment. However other specialist subjects such as the conditions that might affect older people had not taken place. Some staff had received awareness training regarding the Mental Capacity Act and Derivations of Liberties, but others had not. We were told that further training was to be arranged. The company encourage staff to complete an N.V.Q (National Vocational Qualification). Information provided showed that 6 carers have attained an NVQ in care. Residents and a relative told us that they were happy with the way staff supported them. One of the ladies the expert be experience spoke with said that the staff were good at helping and talking to her. Overall staff said that they felt well trained and supported and they demonstrated a satisfactory knowledge of the people they were caring for. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31. 33. 35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems in place help to ensure the health and welfare of people who live at the home. EVIDENCE: There has been no registered manager over the last 2 years. The acting manager, Mrs Carole Johnson, has worked at the home for almost a year and she told us that she would be submitting an application to become the Registered Manager shortly. She is a qualified nurse with experience in managing a care home. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 20 People told us that they had no concerns with how the home was managed and said that the manager and her deputy were helpful and supportive. The manager’s office is at the rear of the home. We noted that throughout the visit she was answering the phone and staff were coming in and out of the office to use the photocopier. This meant that it was difficult to have a uninterrupted confidential conversation with her. This subject was discussed with the manager and the owner. The expert by experience reported ‘In general I came away feeling it was a comfortable place for people living there and that things were changing for the better’. Staff were enthusiastic about their work especially the development of the dementia unit. When asked what the home did well 2 staff said training and communication with residents were good. When asked if there were any areas that could be improved one person said ‘activities especially outings’ and another said that a minibus would be useful to take people out more. The home has a quality assurance system so that they can gain the views of the people who use the service. This included meetings and a suggestion box. Surveys had been sent out in October 2008 and those sampled contained positive responses. People told us that the owner visited regularly. However the monthly reports he is required to complete to assess how the home is operating and demonstrate what actions are being taken to address any shortfalls were not available at the home. The file contained only 2 of these reports for the last 12 months, although some others were later sent to us. The need to keep these reports in the home was discussed with the owner. There is a system in place for residents monies to be held in safe keeping by the home. This includes keeping a running total of all transactions and obtaining receipts and signatures. The home has health and safety polices and procedures to guide and instruct staff. There is also a programme in place to service and maintain equipment in the home on a regular basis. Information provided in the AQAA demonstrated that regular checks on equipment, such as fire equipment and hoists, had taken place as scheduled. At the Environmental Health Inspection last year the kitchen was awarded a 5* rating, this being the highest rating available. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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 OP3 Regulation 14 Requirement A comprehensive assessment process must be undertaken prior to people being admitted to the home. This will help to ensure that the home can meet the needs of anyone who comes to live there. 2. OP19 16 All areas of the home must be 30/10/09 maintained to a good standard of repair and cleanliness. This will help to make sure that the home is fit for purpose. The provider must make monthly 25/09/09 visits to the home and a report produced recording their findings. This will enable them to assess if the home is operating in a satisfactory way. This requirement has not been fully met. Although the provider has produced some reports the content did not cover all the required areas and they had not been kept at the home. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 23 Timescale for action 25/09/09 3. OP37 26 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 OP30 Good Practice Recommendations It is strongly recommended that all staff receive training appropriate to their role regarding the Mental Capacity Act, 2007 and the Deprivations Of Liberties. This will help to ensure that they are aware of their role in protecting people’s rights and choices. The training programme should be reviewed to make sure that it includes all the specialists training required, such as conditions affecting older people. 2. OP30 Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 Page 24 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Welbourn Hall Nursing Home DS0000070035.V377310.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!