CARE HOMES FOR OLDER PEOPLE
42-44 Westfield Drive 44 Westfield Drive Loughborough Leicestershire LE11 3QL Lead Inspector
Chris Wroe Unannounced Inspection 15th February 2006 02:00 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.V283724.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 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.V283724.R01.S.doc Version 5.1 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 232633 shaunogrady@abbeyfield_loboro.com 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.V283724.R01.S.doc Version 5.1 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. 6th September 2005 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. 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. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a weekday, 10th January 2006, starting at 10.20am and lasting for five hours. A senior care worker and care co-ordinator were present during the inspection. Seven residents were spoken with during the inspection, all of whom gave mainly positive views about the home. Comments made include: ‘I am very happy living here’. ‘The food is excellent’. One family, who were visiting a relative, also gave their views about the home. They said that they felt the home was very clean, the care was very good, and small personal touches made them realise that their relative’s needs were really recognised and understood. The main method of inspection used was ‘case tracking’, which involved selecting four residents and tracking the care they receive through checking records, talking with the residents and with staff, looking round the home and observing care practices. At the last inspection, all of the key standards were checked. At this inspection, the inspectors looked at a number of aspects to make sure good care was continuing. What the service does well:
This is based on aspects checked during this inspection: Care staff show a good understanding of the needs of residents. Staff have had training in relevant care issues, such as dementia awareness, which helps them to give sensitive support to residents. Staff spend time with residents if needed, to help them to feel reassured and comfortable. There are care plans in place and risk assessments relating to residents’ ability and safety in moving around the home and need for physical support. Medication is stored safely and records are kept to show that medication is administered in line with instructions from GPs. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 6 There is a range of activities in the home, which are offered to residents to take part in. Specific time is given for one to one support and leisure time for residents. Residents are supported to maintain ongoing contact with family and friends and to go out in the community if they choose to and are able to. The premises are in a good state of repair and decoration, and all areas seen were found to be clean and hygienic. Residents are able to have their own possessions in their bedrooms. The lounge areas are comfortable. There are accessible bathrooms and toilets for residents’ use. Consideration is given to helping residents find their way around the home, with photos of residents outside their bedroom doors. During the inspection, refurbishment work was taking place in the laundry. Notice had been given to relatives and residents and arrangements were in place to ensure that laundry services were still carried out. Staff receive ongoing training in different aspects relevant to their work. Staff feel supported and valued. Residents feel that staff are caring and do their job well. Staff find management in the home approachable. There is a sense of team work. Measures are in place to ensure the health and safety of residents, in relation to safe storage of chemicals, servicing of equipment, testing of safety equipment. The home is supported by a maintenance team and a health and safety officer. What has improved since the last inspection? What they could do better:
It would be good if the provider looked in more details at ways to reduce the number of falls experienced by some residents in the home, such as by developing a falls prevention programme, (which may be carried out in conjunction with the local health authority). Risk assessments could contain more detail about aspects, other than mobility, relating to residents’ safety, such as any impact on behaviour of dementia, or risk of vulnerability.
42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 7 It would be good if the provider paid some attention to addressing current problems occurring in the changeover of recording information from paper to computer, so that recording of aspects relevant to residents’ care could be ensured to be accurate and accessible to staff. The provider must ensure that any serious incidents affecting the welfare of residents are reported under relevant procedures and regulations, as required, so that all residents are fully protected from risk of harm. 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. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 8 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.V283724.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 Residents’ benefit from staff who are able to meet their assessed needs. EVIDENCE: Care staff show a good understanding of the needs of residents. Staff have had training in relevant care issues, such as dementia awareness, which helps them to give sensitive support to residents. Staff spend time with residents if needed, to help them to feel reassured and comfortable. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Residents’ health and medical needs are mostly well met. EVIDENCE: There are care plans in place and risk assessments relating to residents’ ability and safety in moving around the home and need for physical support. Risk assessments could contain more detail about other aspects relating to residents’ safety, such as any impact on behaviour of dementia, or risk of vulnerability. Medication is stored safely and records are kept to show that medication is administered in line with instructions from GPs. Senior care staff are responsible for giving out medication, and they receive training to give them the skills and knowledge to do it safely. There is quite a high number of recorded falls in the home, particularly for some residents. Staff do pay attention to trying to find out the cause of falls and support residents to prevent further accidents, but it would be good if this was developed further. It is recommended that the provider looks at
42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 11 developing a falls prevention programme, (which may be carried out in conjunction with the local health authority) to ensure that the problem of residents’ falls is fully addressed, with the aim of minimising falls in the home. Systems in the home are currently being changed from paper recording to computer recording. This includes information about residents, such as care plans, risk assessments, daily records, details of GP visits and other health checks, and details of medication. Information was found to be missing and in some cases incorrectly recorded – so there are some problems with the changeover. It would be good if the provider paid some attention to addressing these problems so that recording of aspects relevant to residents’ care could be ensured to be accurate and accessible to staff. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 Residents’ benefit from support to enjoy a good daily life and social activities. EVIDENCE: There is a range of activities, which are offered to residents to take part in. Specific time is given for one to one support and leisure time for residents. On the day before the inspection a Valentine’s tea with singing and music was offered to residents. There is also a reading group in the home. Videos, reading books and talking books are available for residents to use. The smaller lounge is available as a quiet room for residents. Residents are supported to maintain ongoing contact with family and friends. One resident’s relatives said that a friend of the resident’s is brought over to visit from a neighbouring home, and that they themselves are always made to feel welcome. Support is given to residents who have dementia, who may wish to walk around and leave the home, to enable them to do so safely with a member of staff, rather than restrict them and not allow them out – this is a positive approach. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents are not fully protected from the risk of harm by procedures in the home. EVIDENCE: Staff are aware of the importance of keeping residents safe from harm and the need to ensure that the home can meet the needs of residents. However, case tracking of one resident revealed that there had been a lack of reporting to the Commission for Social Care Inspection, of a number of incidents potentially affecting the welfare of residents. The home is required to report such incidents under Regulation 37, Care Homes Regulations 2001. There were also aspects of concern, which should have been brought to social services’ attention under the multi-agency Mistreatment of Vulnerable Adults Procedures. This may have resulted in residents not being fully protected from risk of harm, although the manager and staff have taken steps to address issues of concern by involving the community mental health team. The provider must ensure that any serious incidents affecting the welfare of residents are reported under relevant procedures and regulations, as required, in order to ensure any aspects of risk are dealt with without delay. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Although the standards were not further inspected on this occasion, many parts of the home were seen during inspection, to ensure an ongoing good standard of provision. The premises are in a good state of repair and decoration, and all areas seen were found to be clean and hygienic. Residents are able to have their own possessions in their bedrooms. The lounge areas are comfortable. There are accessible bathrooms and toilets for residents’ use. Consideration is given to helping residents find their way around the home, with photos of residents outside their bedroom doors. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 15 During the inspection, refurbishment work was taking place in the laundry. Notice had been given to relatives and residents and arrangements were in place to ensure that laundry services were still carried out. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 Residents benefit from sufficient numbers and good training of staff. EVIDENCE: There were sufficient numbers of staff on duty during the inspection to ensure that residents’ care needs were met. Staff receive ongoing training in different aspects relevant to their work. Some staff have undertaken National Vocational Qualifications. One member of domestic staff said that as well as doing training specific to her role, she has also done training in dementia awareness - which has helped her in her communication with residents and understanding of needs. Residents and relatives felt that staff were well trained and do their job well. The provider is commended for the training provided to staff. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key standards under this section were checked at the last inspection. EVIDENCE: Although specific standards were not inspected on this occasion, the following aspects were noted during inspection: Staff described that they feel supported and valued in their work. Staff find management in the home approachable. There is a sense of team work. Measures are in place to ensure the health and safety of residents, in relation to safe storage of chemicals, servicing of equipment, testing of safety equipment. The home is supported by a maintenance team and a health and safety officer.
42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 18 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 19 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 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 20 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. 1 Standard OP23 Regulation 37 Requirement The provider must ensure that any serious incidents affecting the welfare of residents are reported under relevant procedures and regulations, as required, in order to ensure any aspects of risk are dealt with without delay. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that staff ensure that risk assessments contain more detail about additional aspects relating to residents’ safety, such as any impact on behaviour of dementia, or risk of vulnerability. It is recommended that the provider looks at developing a falls prevention programme, (which may be carried out in conjunction with the local health authority) to ensure that the problem of residents’ falls is fully addressed, with the aim of minimising falls in the home. It is recommended that the provider pay attention to
DS0000001688.V283724.R01.S.doc Version 5.1 Page 21 2 OP8 3 OP7 42-44 Westfield Drive addressing problems arising out of the transfer of information and systems from paper to computer so that recording of aspects relevant to residents’ care could be ensured to be accurate and accessible to staff. 42-44 Westfield Drive DS0000001688.V283724.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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