Wellburn House

We found the following examples of good practice.

The home was clean and tidy. Domestic staff had detailed cleaning schedules to support this and this was monitored by the management team.

The home had good supplies of PPE and other infection control measures to support staff throughout the COVID-19 pandemic.

Relatives were encouraged to become essential care givers and were able to visit their loved ones safely due to the screening programme in place, which included testing. Other technologies were also used to help people maintain contact with those important to them.

Wellburn House provides care for up to 35 people, some of whom may be living with dementia.

Wellburn House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The staff team were aware of their responsibilities under the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

The service provided structured activities for people as well as hiring entertainment. The service was developing strong community links that would broaden the range of meaningful activities for the people who lived at Wellburn House.

The staff team understood how to protect adults from situations in which they would be vulnerable to harm and abuse. Staff had received suitable training and talked to us about how they would identify any issues and how they would report them appropriately. Risk assessments and risk management plans supported people well. Arrangements were in place to ensure that new members of staff had been suitably checked before commencing employment. All new staff completed an induction.

Any accidents or incidents had been reported to the Care Quality Commission as necessary and suitable action taken to lessen the risk of further issues. Risk assessments and care plans provided guidance for staff in the home. Where possible, people in the service were involved in writing care plans.The management team had ensured the plans reflected the person-centred care that was being delivered.

The registered manager ensured that there were sufficient staff to meet people's needs in a timely manner, this included care training for both kitchen and domestic staff. Staff were suitably inducted, trained and developed to give the best care possible. We observed kind, patient and suitable support being provided. Staff knew people well. They made sure that confidentiality, privacy and dignity were maintained. Staff were suitably skilled in providing end of life care and were able to discuss good practice, issues around equality and diversity and people's rights.

Medicines were appropriately managed in the service with people having reviews of their medicines on a regular basis. People in the home saw their GP and health specialists whenever necessary and were able to attend hospital appointments.

We saw that an assessment of needs was in place. People were happy with the food provided and we saw healthy meals that staff supported and encouraged people to eat. The home itself was clean and comfortable on the day we visited. Suitable equipment was in place to support people with their mobility.

Complaints and concerns were suitably investigated and dealt with and good records management was in place in the service. There was also a quality monitoring system in place which was used to support future planning.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Wellburn House on our website at www.cqc.org.uk

Wellburn House provides residential care for up to 35 people, some of whom are living with dementia. At the time of our inspection there were 34 people living at the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had made improvements to their medicines administration and ensured that when people were asleep, staff returned a little later to give them their medicines. Although improvements had been made to address the issues we had found at the last inspection, there were further areas that needed improved and we made a recommendation.

People felt safe and staff understood their roles and responsibilities regarding safeguarding people from avoidable harm or abuse. Risks had been identified in the majority of cases, although we did find two occasions were the records weren’t satisfactorily detailed. The registered manager addressed this during the inspection. Accidents and incidents were dealt with appropriately and monitored by the provider to eliminate as much risk as possible. Emergency procedures were in place to support staff, should a crisis situation occur.

We found the service to be clean and tidy. The provider had improved the environment and the safety of the building by completing a programme of refurbishment, which included new doors and windows and updating their five year electrical certificate (which had been an area of concern at the last inspection).

There were enough staff employed and procedures in connection with the employment of new staff continued to be robust and safe recruitment practices were followed.

People were involved in meetings held at the service along with their relatives. The management team completed a number of audits and checks to ascertain the quality of the service provided and make changes as necessary. We noted some further areas to improve upon and have made a recommendation.

The majority of people and their relatives and staff with whom we spoke, were complimentary about the registered manager and management team. However, we did receive some negative comments.

We have made two recommendations in connection with mattress audits and medicines management.

The last inspection of this service took place in January 2016 when the provider was found to be in breach of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, entitled Safe care and treatment and Good governance respectively. At that time the service was rewarded a rating of 'Requires Improvement'. Following that comprehensive inspection, the provider sent us an action plan in which they told us what they planned to do to meet the relevant legal requirements they had breached.

This inspection took place on the 11 and 12 May 2017 and was unannounced. We carried out this inspection to check that improvements had been made and also to carry out a second comprehensive inspection in line with the revisit timescales associated with the rating the provider was given at our last inspection. We found that in relation to the concerns identified at our last visit, improvements had been made. However, further evidence of shortfalls in the same regulations were also identified.

A registered manager was in post at the time of our inspection who had been registered with the Commission to manage the carrying on of the regulated activity since December 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe living at the home and in respect of the care that they received. However, we identified shortfalls with the management of medicines which indicated that people did not always get the medicines they were prescribed. Some people were regularly asleep or refused their evening medicines and this pattern had not been identified and addressed by the registered manager or staff. This included people who needed anticoagulant medicines to reduce the risk of blood clotting and epilepsy medicines to control seizures. In addition, recording around the administration of topical medicines was not robust and body maps in place to support staff with where and how often to apply particular creams and ointments, were not always complete.

Risks associated with people's care had not always been identified and addressed. Environmental risks had also not been identified such as fire exits that opened onto staircases not being fitted with appropriate exit controls to prevent people with cognitive impairments from exiting through them, before staff could reach them. Other risks associated with the electrical installation of the building had been identified through an electrical inspection of the home, but remedial work to make these safe was not always carried out in a timely manner.

We also identified shortfalls with the management of people's care records. Care plans and risk assessments were not always in place for key needs that people had. In addition, some recording throughout the service was poor. We found gaps in recording around the administration of topical medicines, there was not always enough detail in daily notes and a lack of completeness and detail in records related to the monitoring of the care people received, and contact with healthcare professionals.

Whilst there were a range of quality assurance checks and audits undertaken, these were not always effective. There was also a general lack of management oversight of the service. The shortfalls that we identified at this inspection had not been identified through the provider's own auditing and checking systems, neither were they identified during visits undertaken by representatives of the provider organisation on a monthly basis.

We received mixed feedback about the registered manager and her leadership style. We discussed this with the nominated individual who took steps following our inspection to look into this matter and some of the issues raised.

Safeguarding policies and procedures were in place and staff understood their own personal responsibilities to safeguard people from harm and abuse. Recruitment procedures were thorough and accidents and incidents were recorded and reviewed to see if measures needed to be put in place to help prevent repeat events.

Staffing levels were sufficient on the days that we visited although staff said these could vary day to day and there were some shifts where they were very busy due to reduced staffing levels. All of the people we spoke with raised no concerns about staffing levels.

Staff were supported with relevant training, supervision and appraisal, in order to deliver care in line with people's needs. Some staff told us where there were issues with their performance, this was not always clearly communicated to them.

People raised no concerns about the way in which they were treated and how their care was delivered. Our observations of care confirmed that staff were pleasant and supportive in their approach and they protected and promoted people's independence, privacy and dignity. We saw staff engaged in pleasant conversation with people and involved them in the delivery of care offering explanations and information when required. Activities were on offer within the home and people were supported to make their own day to day choices. The care people received on a day to day basis was person centred.

The provider had a complaints procedure in place that was brought to people's attention in a service user guide that they were issued with when they started using the service. Relatives also told us they were aware of how to complain should this be necessary. Feedback from people, their relatives and staff about the standards of care delivered, was obtained via questionnaires and meetings held regularly within the service.

Overall people's healthcare needs were met and when they presented as physically unwell appropriate input into people's care from general practitioners and other relevant healthcare professionals was obtained. There were shortfalls however in the respect that risks and poor management of medicines which may have had a direct impact on people's health and wellbeing, were not always identified by staff and management. People's nutritional needs were met and where they needed their food cut up or softened for example, this was done for them.

CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty safeguards. The Mental Capacity Act (MCA) was appropriately applied and applications to deprive people of their liberty lawfully had been made to prevent them from coming to any harm where they lacked capacity. The service understood their legal responsibility under this act and the registered manager told us they assessed people’s capacity when their care commenced and on an on-going basis when necessary. They also told us that decisions were made in people’s best interests when necessary, although records about such decision making and any associated capacity assessments needed to be improved. This was being reviewed at the time of our inspection by the compliance manager.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely Regulation 12 entitled Safe care and treatment, and Regulation 17 entitled Good governance. You can see what action we have asked the provider to take at the end of the full version of this report. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We carried out an inspection in December 2012 and found they were not meeting the regulation relating to infection control. We undertook a follow up inspection in May 2013 and found that improvements had been made and the service was meeting this regulation.

Wellburn House is a two storey detached home situated in Ovingham, Northumberland which offers residential accommodation. The service can accommodate up to thirty five people, some of whom were living with dementia. Nursing care is not provided. There were 28 people living at the home at the time of the inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they felt safe. We found however, that a safeguarding concern had not been reported to the local authority. In addition, four safeguarding incidents which had been reported to the local authority had not been notified to the Care Quality Commission (CQC).

We passed our concerns to the local authority's safeguarding and contracts teams.

Most people, relatives and staff told us there were enough staff to meet people’s needs. We saw that people’s needs were met by the number of staff on the day of the inspection. However, staff rotas did not always evidence how many staff were on duty to ensure adequate staff were deployed. Night staff told us and rotas confirmed that sometimes there were only two staff on duty at night due to last minute sickness. There was no evidence that these reduced staffing levels had been assessed in case people needed to be evacuated in the event of an emergency. We have made a recommendation that staffing levels are assessed to ensure that people can be evacuated safely in the event of an emergency. We passed our concerns to the local authority’s fire safety team.

We found that safe recruitment procedures were followed.

Some of the fitted radiator covers were not suitable and would not protect people from the risk of injury. Medicines were generally managed safely. ‘When required’ medicines care plans were being formulated to inform staff when these should be administered. We have made a recommendation about the management of some medicines.

There was a training programme in place. Staff were trained in safe working practices and to meet the specific needs of people who lived at the service.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals.” The registered manager had submitted DoLS applications to the local authority to authorise in line with legal requirements.

People were supported to receive a suitable nutritious diet. We looked in the kitchen and food storage areas and observed that there was a wide variety of fresh fruit and vegetables.

People and others with whom we spoke were complimentary about the service and staff. One person said, “I’ve been all over, but this is the best place. The food is the best.” A relative described it as “outstanding.”

Feedback was obtained from people in the form of surveys. Complaints were recorded and people knew how to complain if they needed to. Accidents and incidents were documented, reported and analysed.

The registered manager carried out a number of audits and checks to monitor all aspects of the service. Staff told us they enjoyed working at the home and morale was good.

The provider had not always submitted notifications to us in line with their responsibilities and legal requirements. We have taken this into account when deciding upon the rating for the well led domain.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment with regards to the premises and good governance. You can see what action we asked the provider to take at the back of this report. We also found a breach of the Care Quality Commission Registration Regulations 2009. This related to the notification of other incidents. This is being followed up and we will report on any action once it is complete.

We found that people's care needs were assessed and their care and treatment was planned. People received care which reduced the risk of poor nutrition and dehydration. Where necessary external healthcare professionals had been consulted about people's dietary concerns.

We looked at how the home managed medicines and found there were appropriate arrangements in place for the safe administration, recording, obtaining, handling, storage and disposal of medicines.

We saw that people had enough equipment available to enable them to maintain their independence as much as possible and this equipment was suitably maintained.

We found the provider had a structured staff selection and recruitment policy in place which aimed to ensure staff were suitably skilled, experienced and qualified to deliver care safely.

At this inspection we also checked whether previous shortfalls in the management of cleanliness and infection had been addressed. These issues had been identified during our last inspection at the service on 28 November 2012. We found improvements had been made and the risks associated with infection had been reduced.

In this report the name of a registered manager (Margaret Armstrong) appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

People told us their consent was gained prior to care being delivered and we found that staff acted in accordance with their wishes.

We found that people's care and support needs were appropriately assessed and their care was planned. They received care safely, and to an appropriate standard.

Staff were well supported, trained appropriately and had opportunities for continued professional development.

We saw the provider had a complaints policy and procedure in place which people had access to within their rooms.

However, although people who received care and support from Wellburn House told us they were happy, and we saw they were well supported, we found that failures to maintain and manage cleanliness and infection control, may put people's safety at risk.

In this report the name of a registered manager (Margaret Armstrong) appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.