Archived: Wells Lodge Nursing Home

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them, and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff personnel records contained all of the information required by the Health and Social Care Act 2008. The provider had developed guidance on recruitment and selection to provide information to staff on the procedures for recruiting new employees. We looked at a sample of recruitment records for four staff. Examination of records and discussion with staff confirmed staff had undergone a comprehensive recruitment process prior to commencing work for the service. This meant the provider could demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. While no DoLs applications have needed to be submitted, proper policies and procedures were in place. We saw that relevant staff had been trained to understand when a DoLs application should be made, and how to submit one. Policies and procedures had been developed by the registered provider to provide guidance for staff on how to safeguard the care and welfare of the people using the service. This included guidance on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS).Training records highlighted that the majority of staff had completed Mental Capacity Act training and Deprivation of Liberty Safeguards training.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Is the service effective?

Feedback received from people using the service was positive and confirmed people were happy with the standard of care provided. Comments included: "I am very happy here'. In relation to meals, one person reported: "The food is very tasty".

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs.

Is the service caring?

On the day of our visit the atmosphere in the home was calm and relaxed. The people living at the service were observed to be comfortable and relaxed in their environment and were able to follow their own plans and preferred routines. Staff were attentive to the diverse needs of the people living in the service and we saw they communicated and engaged with the people they supported in a respectful, dignified and caring manner.

We found that people living at the service had been invited to take part in their own plan of care. The registered manager and staff were observed knocking on doors and calling people by their preferred name. One relative we spoke to told us 'The staff were so caring'. Another person told us 'my relative gets all the care they need'.

Is the service responsive?

People's needs had been assessed before they moved into the home. Records we saw confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

The registered provider had developed a complaints procedure. A 'complaints and comments' booklet had been produced to provide people using the service an and / or their representatives with information on how to provide feedback on the service provided.

We received one complaint from people using the service during our visit. This was discussed with the operation manager and acted on promptly.

People told us they were asked for their feedback on the service they received and that they had also filled in a customer satisfaction survey. They confirmed they had been listened to and as a result of the survey changes to the menu had been made.

Is the service well- led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities.

The service has a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

People told us that staff made sure that their healthcare needs were responded to and that staff had a good understanding of their individual treatment and support needs. Care records were detailed and contained care plans that staff were seen to follow in practice. Risks to people's safety and welfare had been identified and minimised as far as possible.

A visitor to the home said 'I don't think we could find anywhere better' and another visitor commented that there was 'good staff interaction'.

All the people we spoke to who use the service told us they felt safe and would know what to do if they had any worries or concerns. One person said that they had no problems, but would feel able to talk to the staff and "they would put it right".

We found that staff were appropriately trained according to their roles and responsibilities and that systems were in place to monitor standards of quality and safety.

In this report the name of a registered manager 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.