Inspection on 01/10/07 for 42-44 Westfield Drive

This inspection was carried out on 1st October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

42-44 Westfield Drive 26/07/06

42-44 Westfield Drive 15/02/06

42-44 Westfield Drive 06/09/05

42-44 Westfield Drive 18/01/05

42-44 Westfield Drive 04/08/04

42-44 Westfield Drive 02/03/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 42-44 Westfield Drive 44 Westfield Drive Loughborough Leicestershire LE11 3QL Lead Inspector Keith Williamson Unannounced Inspection 1st October 2007 09:00 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 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 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. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 42-44 Westfield Drive Address 44 Westfield Drive Loughborough Leicestershire LE11 3QL 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) 01509 210708 01509 266616 The Abbeyfield Loughborough Society Limited Mr Shaun O`Grady Care Home 31 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15), Old age, not falling within any other category (31) 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers No-one falling within category DE(E) or MD(E) may be admitted into the home when there are 15 persons in total of these categories/combined categories already accommodated within the home. 26th July 2006 Date of last inspection Brief Description of the Service: 42-44 Westfield Drive is registered to provide care for thirty-one older people including up to fifteen people who may have dementia or mental disorder. The home is situated close to Loughborough town centre and the University, and near to a bus route and local shops. The premises are pleasantly decorated and furnished to a high standard. Bedrooms are situated on the ground and first floors. Access to the first floor is available via two passenger lifts. In March 2003, the home opened the Jean Cope Wing, which contains twelve rooms with en suite facilities. In addition to their rooms, residents have access to a lounge and a large lounge/dining room. There is a well-maintained garden to the rear of the property. The Statement of Purpose and Service User Guide and the current inspection report are available for new residents. (This is information about how the home is managed and the facilities provided.) A copy of those and the last report are available along with other individual information in the foyer of the home. At the time of the visit the range of fees charged fall between £436.59 and £473.53 per week. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections is on outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting a sample number of clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation, in this case four residents were chosen. This unannounced inspection by one Inspector took place over one day, commencing at 9.00am and took seven and one half hours to complete, during which the Registered Manager was present and highly cooperative throughout. One inspector conducted the inspection (or site visit). An opportunity was taken to look around the home, view records, policies and care plans and to talk to residents and staff. Information was gathered prior to the site visit from sources such as residents, their relatives and staff comment cards; the pre inspection questionnaire from the registered manager and in some cases complaint information. Most of the residents were seen and three residents and a relative were spoken with during the visit. Some of the comments made at the time have been included in this report. One requirement and four recommendations were made as a result of the last inspection and all of these have been met, or are currently being worked on. What the service does well: Residents are given good information and are able to visit the home before they decide whether they want to live there. They are provided with a good plan of care, that is reviewed regularly, and the choice to include relatives and friends in that as well. One residents spoken with confirmed, “staff were nice and treat us well”. Discussions with a visiting health care professional resulted in the person stating the staff provide “good care” and are “conscientious and professional”. Residents are able to bring their own things to the home like pictures and small pieces of furniture. The home helps residents keep in touch with their family and friends. Residents are able to carry on going to church and to practice their faith, in the home too. Residents are able to choose how they spend their time and to make decisions about their day, like when to get up and go to bed. The building is well looked after, safe and free from odour. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 6 There are enough staff working in the home to make sure that the residents are well looked after and are safe. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 42-44 Westfield Drive DS0000001688.V341212.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 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The assessment process for residents is detailed and effective; resulting in detailed information for staff to ensure care needs shall be met. EVIDENCE: There is a Statement of Purpose, which sets out the latest aims, objectives and philosophy of the home, about its services, facilities, and current staffing. This document needs to be updated; the Registered Manager stated he planned to up date this in the near future. Residents have individual contacts, which set out the terms and conditions of residency and access to the service users guide. The Registered Manager confirmed that residents are assessed prior to admission and that the pre admission format is currently being reviewed to 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 9 ensure that residents are fully assessed for all of their needs including mental and emotional health as well as physical. Residents spoken with confirmed satisfaction with their own experiences of the admission processes, having had adequate information provided about the home and opportunities to visit prior to deciding whether they would like to live there. The home does not offer intermediate care. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is successful in delivering appropriate care to individual residents EVIDENCE: All of the residents’ case tracked had appropriate plans of care developed and there was evidence that these are regularly reviewed and wherever possible involved the resident or their representative. Care plans contain detailed instruction to staff about how residents’ physical and emotional needs were to be addressed. There was evidence to demonstrate that that care was being delivered according to the individual plans of care. Key workers and other staff demonstrated a good understanding of the residents needs and residents spoken to confirmed this. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 11 All the case tracked residents had appropriate risk assessments for the management of pressure, falls and nutrition, which in general demonstrate that the appropriate interventions are in pace. Residents and a relative spoken with confirmed that “staff were nice and treat us well”. Medication systems are managed well; a spot check was conducted, the monitored dose system was found to correspond with the medication administration records and were found to be in good order. The Registered Manager confirmed that residents who chose to self medicate have appropriate risk assessments conducted. A resident and relative confirmed that the privacy and dignity of residents was respected at all times. Staff were seen to relate well to residents, to knock and await permission prior to entering their private accommodation. Personal care and consultations with medical staff were conducted in private. Discussions with a visiting health care professional resulted in the person stating the staff provide “good care” and are “conscientious and professional”. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Daily life and social activities are managed well. EVIDENCE: Residents spoken to confirmed that routines were flexible and varied. One resident stated that she had lots of freedom and flexibility in her day. Records of activity evidenced that residents had access to a good and frequent range of personal and community activities. The residents confirmed this. The home is Christian based and residents are supported to maintain their faith through all aspects of their daily lives. One resident confirmed that he was able to maintain his participation in church activities outside of the home. Residents confirmed that they are able to receive their chosen visitors in private should they wish. Relatives were seen coming and going throughout the day, one confirming visiting was unrestricted. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 13 Residents confirmed that they are supported to maintain choice and autonomy in their daily lives and that they are able to handle their own finances. Residents’ rooms appeared to have a number of personal items. Lunch was viewed being served, and though no recognised choice of main course existed, the staff indicated residents had another choice if they didn’t like the first. There was a choice of hot and cold sweets meals appeared well presented. Residents confirmed satisfaction with the food provided by the home Staff serving lunch were appropriately attired for food hygiene purposes. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints and protection are managed well. EVIDENCE: There is an appropriate complaints policy, which is accessible to residents and their representatives. Residents confirmed that they knew how to make a complaint; one stated that they would feel confident in raising any concerns and had confidence that these would be appropriately addressed by the Registered Manager. The Commission for Social Care Inspection have received no concerns passed to them about this service. Staff have received training in the Protection Of Vulnerable Adults and were knowledgeable about the action that would need to be taken in the event of an abusive situation. A staff notice board situated in the main foyer of the home, raises the level of protection offered to residents. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The premises are well maintained, offer a good standard of accommodation and are clean and hygienic. EVIDENCE: The entrance to the home provides the residents and visitors with information on past inspections, a copy of complaint information and the Service User Guide. The corridors are wide with handrails and are bright and well decorated and resident’s bedrooms are off the main corridors, all offer single accommodation with twelve including toilets and wash hand basins. The first floor bedrooms are reached by the stairs, two passenger lifts or stair lift. The garden and the surrounding areas near the home are well maintained. Residents’ bedrooms are individual in character; spacious, well decorated and personalised with the residents’ own belongings. Bathrooms and toilets were 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 16 clean and equipped with a variety of equipment to assist residents and staff. All the bathrooms and toilets lock appropriately, and a supply of aprons, gloves and antibacterial gels for use. The manager and members of the Health and Safety team hold four meetings a year to monitor the home environment, and decide on areas for upgrading and future development. A record of these meetings was seen, and is used as the basis of the refurbishment plan. The laundry room is situated away from the kitchen with a team of domestic and laundry staff responsible for the cleaning and laundry. Staff confirmed they have ample supply of protective clothing to manage control of infection and care staff were observed wearing protective clothing throughout the day. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The numbers of staff and thorough recruitment process ensures resident safety in the home. EVIDENCE: There are adequate numbers of staff working in the home. Staff and residents confirmed that staffing levels were sufficient to meet the needs of residents. Staff files and staff spoken to confirmed access to appropriate training, including induction and mandatory training such as Fire Safety, Movement and Handling, First Aid, Food Hygiene, Health and Safety and Infection Control. The Registered Manager confirmed that staffing levels are calculated according to the guidance issued by the Department of Health and that these levels are based on the assessed levels of residents dependency. Staff spoken with confirmed that they have opportunities to gain appropriate qualifications; some had already achieved both National Vocational Level two and three in care. Newer staff confirmed that they had been involved in discussions about their wishes to undertake this training. The Registered 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 18 Manager estimates that approximately 75 of current staff have NVQ level 2 qualifications in care. Recruitment practices were seen to be satisfactory with appropriate references and Criminal Records Bureau Clearances having been obtained. Staff spoken with confirmed the application process and interview; one stating the process was “very thorough”, and the questions asked at interview were “searching”. 42-44 Westfield Drive DS0000001688.V341212.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management approach promotes effective care practice in the home so ensuring residents’ care and protection. EVIDENCE: The Registered Manager is qualified through completing the National Vocational Qualification level four in care and Registered Manager Award. Quality Assurance systems are in place, which include internal audits of medication systems, falls and annual residents satisfaction surveys. The results of which are currently being collated. The registered manager confirmed that 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 20 the Quality assurance Systems were to be reviewed and strengthened in the near future. Staff spoken to confirmed the procedure, which is used to monitor residents financial transactions, these being in line with the Abbeyfields Policy on Handling Residents Finances The Heath and Safety of residents is managed well with appropriate risk assessments being in place. The Registered Manager is liasing with a falls prevention Coordinator Leicester and Rutland Trust to establish a working Falls Prevention Policy. Accurate accident records are maintained and no hazards were identified. Periodic tests are performed by the property manager ensuring that Health and Safety standards are adhered to. These include fire alarm and emergency lighting, and planned Legionella testing. The home is free from odours and is kept to a high hygienic standard. 42-44 Westfield Drive DS0000001688.V341212.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations The Registered Person should update the Statement of Purpose, to ensure prospective residents and their relatives have access to full and appropriate information prior to commencing a stay at the home. 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Extracts may not be used or reproduced without the express permission of CSCI 42-44 Westfield Drive DS0000001688.V341212.R01.S.doc Version 5.2 Page 24 - 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!