Inspection on 30/11/05 for West Dean

This inspection was carried out on 30th November 2005.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Dean 14/11/06

West Dean 09/08/05

West Dean 23/02/05

West Dean 01/09/04

West Dean 25/02/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 West Dean 77/79 Yarborough Road Lincoln Lincs LN1 1HS Lead Inspector Roger Harrison Unannounced Inspection 30th November 2005 09:45 West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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 West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service West Dean Address 77/79 Yarborough Road Lincoln Lincs LN1 1HS 01522 568248 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) westdean@unitedheath.co.uk United Health Limited Care Home 16 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (10) of places West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: West Dean is a care home providing personal care for 16 residents who have a learning disability or mental health need. West Dean is not registered to provide Nursing care. The home is a large detached property located on a steep hill on one of the key routes within the City of Lincoln. The home is set back from the main road a within its own grounds and garden. There is access to the front of the home through the main entrance, which has a number of steps. There is also access to the rear of the home by way of the parking area, which is set on a steep slope. The property has four floors. There are two self-contained flats on the ground floor. These are used as pre-discharge facilities, which support residents who are choosing to move into the community. The home is one of a group of homes owned by United Health PLC. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over a four and a half-hour period, by two inspectors using a method of inspection called “case tracking”. This involved selecting three residents who currently live at the home and tracking their experience of the care and support they have received during the time they have lived at the home. This was achieved by the inspectors touring the home, looking at information on care plans and files, talking to residents and care staff, and observing day-to-day care practice within the home. What the service does well: What has improved since the last inspection? What they could do better: The Acting Manager has worked hard to update all care plans so that they provide clear, detailed information regarding the needs of residents. These plans would benefit from being updated further to include social histories, objectives and outcomes which can be reviewed in order to evidence the good practice observed, and to support residents in fully meeting their personal goals. Arrangements to collect household rubbish from the home need to be changed to ensure it is stored more appropriately whilst awaiting collection. A part of the garden at the front of the building would be improved through the removal of rubble left over from repair work at the home. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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 West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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): 2 and 3. Detailed assessments are carried out with any new resident before admission, which are used to identify and support individual needs and wishes. EVIDENCE: The home has a service user guide, which residents told the inspector they were aware of, and had access to. Residents personal files showed that there had been visits made to the home before admission for some new residents and, where this was not possible a visit made by staff from the home to the individual before admission to undertake an assessment of needs, provide information on how the home is run, and about what sort of support to expect. One resident told the Inspectors that; “I had a choice of three rooms when I came here, and I was supported to choose the room I wanted by the staff team”. Residents told the inspector that they were able to discuss any concerns before moving into the home and were able to make choices about activities and the level of support provided together with care staff. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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. Residents have care plans in place, which could be improved further, to fully reflect individual goals and aspirations. EVIDENCE: Each resident has a detailed care plan, which has been developed to reflect individual assessed day-to-day physical needs. Care plans have been updated by the acting manager since the last inspection. All residents have a risk assessment separate to, but linked to their individual care plan. Care plan reviews are undertaken as appropriate and risk assessments are reviewed in a structured way. Where there are changes in need, the home undertakes further, more detailed risk assessments, which involve residents, and where appropriate their family carers. Any action taken is recorded within residents care records. This enables residents to be fully involved in any decision-making and to be supported to take risks in the way they wish to. Although comprehensive in terms of highlighting physical needs, Care plans would benefit from being updated further to provide evidence of appropriate involvement from community professionals, and to include social histories, personal goals, and action plans, with outcomes, which fully promote residents aspirations. This was discussed with the acting manager on the day of inspection, who agreed to undertake the task. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 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): 12, 13, 16 and 17. Residents are supported to take part in appropriate activities within the home and local/wider community. Residents are also encouraged to maintain family relationships and to develop relationships with other residents with support as they wish. The home provides a varied and balanced nutritious diet for residents. EVIDENCE: The Acting Manager told the inspectors that residents are encouraged to develop practical life skills as part of their overall care plan. Additional hours have been provided for staffing to support residents with social activities linked to care plans. Plans show that residents are given opportunities for personal development and engage in leisure activities. Residents were observed throughout the inspection, coming and going freely and undertaking activities of their choice as they wished. One resident was observed welcoming a friend into the home after undertaking Christmas shopping. Staff told the inspector of the need to promote choice and independence, which was further evident when talking to a resident who lived in one of the homes two self contained flats. The resident told inspectors that he felt well supported to live safely and as independently as possible. Menus at the home are currently being planned on a weekly basis whilst work is completed on the installation of a new kitchen at the home. Residents told Inspectors that “The food here is really good” and West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 11 that they are able to contribute to menu planning at the home. Residents confirmed that if they want an alternative to the menu of the day it is provided for them. . West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 12 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): 18, 19 and 20. Residents are protected by policies and procedures within the home, which are used to ensure health needs are met in the right way and to understand wider needs in order to encourage choice and self-determination wherever possible for all residents. EVIDENCE: Each resident has a named key worker. This system helps to promote a relaxed and measured approach to care giving by a care team who know the needs of the residents they work with. This also helps to create a calm enviroment where staff anticipate when and where needs require meeting, so that appropriate action is taken when needed which minimises any disruption and stress for residents. Care plans looked at have been updated to include all health related needs, and staff support residents to attend GP and other health care appointments within the community when this is needed. Some residents at the home require support with medication. There are policies and procedures for recording all aspects of administering medicines. Records are kept up to date and only the Acting Manager and trained senior care staff administer medication to residents. Those residents who are supported to self medicate have locked storage in their rooms. On the day of inspection two residents were able to show inspectors how they were supported to manage their own medicines safely. The home is further developing its main storage facility for medication; current storage is appropriate but would benefit from an additional storage cupboard to safely store newly delivered medicines. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 13 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): 22 and 23. Individuals are encouraged to be open about their feelings and concerns. The home takes the protection of residents seriously, and acts to support and protect residents. EVIDENCE: The acting manager told inspectors that he encourages residents to talk about any concerns they may have and has set up residents meetings to enable greater opportunities for those living at the home to air their views. The home has a copy of the policy, procedure and guidance relating to the protection of adults. Staff files looked at confirmed that team members had received training in adult protection, and during the inspection a staff member described appropriate action that should be taken if a resident raises concerns regarding abuse. Residents told the inspectors that they felt they could talk to any member of staff at any time and that there is always someone available to talk to if needed. One resident told the inspectors that “ I feel safe here, its much better than where I used to live and the manager and staff are very supportive” There are two lounges within the home, which are used for activities, quiet space and for residents meetings. A group of residents told the inspector that they meet together with staff to discuss any ideas or problems formally on a monthly basis or whenever they need to, that they feel protected by the care team and that their views are fully heard. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 14 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 and 30. Internally the home is clean and provides a supportive environment for residents. Externally, arrangements for the collection of household rubbish need to be improved, and part of the grounds at the front of the building need to be cleared in order to fully promote the health and safety of all residents EVIDENCE: The home was observed to be clean and well maintained. A programme of refurbishment has commenced and a new kitchen is currently being installed at the home. Residents, told the inspectors they had access to all the private and communal facilities that they needed and were aware of fire safety and were able to describe what to do, and where to gather in any emergency. The care team told the inspector that health and safety is taken seriously within the home. All residents have their own rooms, which are made personal by each individual. All rooms are numbered for each resident and residents have their own keys for rooms. Residents told the inspector it was easy to get to local amenities and support services to meet their needs. Residents talked about West Dean as “their home” and the inspectors observed residents freely going about a variety of daily activities as they wished. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 15 The home currently uses the local council to collect rubbish from the home. This is undertaken regularly but does mean that rubbish accumulates outside the home each week. This issue was discussed with the acting manager, who agreed to arrange for rubbish to be removed more appropriately by a contractor. This would enable an appropriate storage container facility to be in place to store rubbish more hygienically. During the inspection it was also noted that a large amount of rubble had been left at the front of the home after some previous repair work had been undertaken. This was discussed with the acting Manager and the responsible individual on the day of inspection. It was agreed the rubble would be removed as soon as possible. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 16 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): 32 and 34. The Acting manager has recruitment procedures in place and provides appropriate levels of support to the care team, who are able to use training provided to support residents within the home and wider community. EVIDENCE: On the day of inspection the home was adequately staffed, with staff, who demonstrated experience and competence to care for the current group of residents. Through the checking of staff files and discussion with the Acting Manager, it was confirmed that a recruitment policy and procedure is in place to ensure that the team is balanced and provides appropriate physical, and social support for all residents safely. The staff team were seen to work well together and told the inspectors that they felt supported by the Acting manager to their job. Care staff told the inspectors they are clear about their roles within the home and that they felt training opportunities are available for them to develop existing and new skills further. The Acting Manager receives support from the Companies personnel and operations manager to identify staff training needs as appropriate to ensure that residents needs can be met by a developing staff team. The Acting manager provides supervision formally for all staff with records maintained and stored securely. Team meetings are also provided to give the care team wider opportunities to contribute to development of practice within the home. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 17 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): 37,39 and 42. The home has a competent and committed Acting Manager who understands the needs of each individual resident. Resident’s benefit from the support given to staff by the manager in maintaining their health, safety and welfare needs at the centre of the care giving, review and development process. EVIDENCE: The acting manager is undertaking an application to the CSCI to be the registered manager. The acting manager has an open “hands on approach” to the role he undertakes and operates flexibly to support the team in their duties. The managers office has been well organised, and provides a base for maintaining all records. These are kept appropriately by the acting manager and used in a structured way by the team to make sure that health and social care needs are met in the way that residents want them to be. The acting manager told inspectors that he understands his role and responsibilities, this was evident throughout the inspection, and wishes to progress to become the homes registered manager in order to continue making a positive difference to resident’s lives, and in supporting the staff team to develop practice in the right way. West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Dean Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000002396.V268362.R01.S.doc Version 5.0 Page 19 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. 1. Standard YA6 Regulation 15(1) and (2)(c)(d). Requirement The Manager must further develop existing individual care plans with each resident which identify services and facilities, and how these services will meet the current and changing needs, aspirations and goals of each resident and reflect outcomes. Storage for medication must be improved and expanded to enable all drugs including newly delivered, ‘changeover’ blister packs to be stored securely. Timescale for action 01/03/06 2. YA20 13(2). 01/03/06 3. YA24 23(2)(o) and (5) External grounds must be safe for use by service users and appropriately maintained. Rubble must be cleared from the front of the building and Arrangements must be made for the hygienic storage and safe collection of domestic rubbish from outside the home. 01/03/06 West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations West Dean DS0000002396.V268362.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 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. 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