CARE HOME ADULTS 18-65
39 Westway Westhill Care Homes 39 Westway Caterham Surrey CR3 5TQ Lead Inspector
Peter Benthom Unannounced Inspection 30th January 2006 16:00 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 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 39 Westway DS0000028581.V274914.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 Adults 18-65. 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. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 39 Westway Address Westhill Care Homes 39 Westway Caterham Surrey CR3 5TQ 01883 382576 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) roshanwest@aol.com Mr Roshan Panchoo Mr Roshan Panchoo Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (1) registration, with number of places 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 35 - 65 years. Any person accommodated within the category of sensory impairment will only have a hearing loss/deafness. 22nd November 2004 Date of last inspection Brief Description of the Service: The home is comprised of a converted semi-detached house and a twobedroom annexe next door accommodating seven people in total. It is situated in a busy road in Caterham near to all facilities and is indistinguishable as a care home, instead blending in well with the local community. All accommodation is of a very high standard. The home is owned by Westway Care Homes which a fairly recently registered service. The proprietor is also the manager of the home. Service Users have severe learning disabilities. All service users are male. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was second of the year 2005/6 and was conducted by an inspector from CSCI. Three members of staff were on duty and four of the five Service Users in the home were spoken with. What the service does well: What has improved since the last inspection? What they could do better:
It was observed that the home is operating extremely well and that all policies, procedures and practice issues are of a very good standard. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 6 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. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/a These standards were not assessed at this inspection EVIDENCE: These standards were not assessed at this inspection 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 The systems for Service User consultation are good with evidence that their views are sought and acted upon. EVIDENCE: Risk assessments were in place where appropriate. During the inspection it was evident that staff respect the Service Users’ right to make decisions. Evidence was provided with examples of the Service Users’ opportunities to participate in the day-to-day running of the home. Staff enabled Service Users to take responsible risks - wherever possible. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Links with relatives, friends and the local community are good. These links support and enrich Service Users social and educational opportunities EVIDENCE: All Service Users go out into the local community on a regular basis supported by members of care staff. The manager stated that Service Users are going out on excursions and holidays, risk assessments were seen as part of the daily activity programme in the home. Service Users had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempt to maintain links with Service Users’ families. There are no restrictions in terms of visiting times. Menus offer a good range of food and use of fresh ingredients is encouraged wherever possible. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/a These standards were not assessed at this inspection EVIDENCE: These standards were not assessed at this inspection 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/a These standards were not assessed at this inspection EVIDENCE: These standards were not assessed at this inspection 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: Overall the home was in very good condition; appropriately decorated, well maintained and furnished to a very high standard. There were sufficient bathrooms and toilets to meet the national minimum standard. The communal areas in the home were considered safe and accessible for the Service Users. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 33, 34, 35, and 36 The staff have a good understanding of the needs of the Service Users in this home. This is evident from the positive relationships that have been formed between the staff and the Service Users. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. Training and development of staff has been given a high priority with 75 staff doing the NVQ and a range of other training to help them care for and support the service users. The manager/proprietor is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. There are arrangements to carry out CRB checks and two written references are required for all staff. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, The manager is well supported by the senior staff team in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager has completed NVQ Level 4 and the Registered Managers Award and has had extensive relevant experience. He is employed full time and works alongside other staff on the rota. There is good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 3 X X X X X 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 17 no Are there any outstanding requirements from the last inspection? 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. N/a Standard N/a Regulation N/a Requirement No requirements Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. N/a Refer to Standard N/a Good Practice Recommendations No recommendation 39 Westway DS0000028581.V274914.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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