Inspection on 09/08/05 for West Dean

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 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 30/11/05

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 LN1 1HS Lead Inspector Roger Harrison Unannounced 9 August 2005 10:00 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 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 Stationary 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 C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service West Dean Address 77/79 Yarborough Road Lincoln LN1 1HS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01522 568248 www.unitedhealth.co.uk Mandy Cheriton-Metcalfe United Health Limited Currently Vacant Care Home 16 Category(ies) of LD Learning Disability Both 6 registration, with number MD Mental Disorder Both 10 of places West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 23/02/05 Brief Description of the Service: West Dean is a care home prviding 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 selfcontained flats on the ground floor which 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 C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken over a five hour period with support from CSCI community Pharmacist Judith Smith. The Inspector toured the building, talked with residents and care staff using a method of inspection called case tracking which involved selecting three residents in order to track the care they receive through the checking of their records, discussion with them, care staff, and observation of care practices within the home. What the service does well: What has improved since the last inspection? What they could do better: The home and residents would benefit from improved storage for medication. Documentation needs to cover all aspects of medicine management and West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 6 administration and procedures for medicine management need to be fully updated. Staff need up to date training in the handling and administration of medicines. 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 C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 standard(s) 2 Detailed assessments are carried out with any new resident before admission, service users are also given information to enable them to make an informed choice about where to live. EVIDENCE: The home has a service user guide which residents told the inspector they were aware of. 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 provide information on how the home is run and what sort of support to expect. 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 C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 standard(s) 7 and 9 The care team promote choice and independence for residents whilst respecting the right for individuals to make choices and take risks with support when needed. EVIDENCE: A group of residents told the Inspector that they were able to make decisions about what they wanted to do with one resident saying “We can do whatever we like here” and “If I need help the staff are always here to talk to”. The home has an open door policy and the inspector observed residents coming and going with one resident meeting a friend within the grounds of the home. There is a system in place for residents to let staff know when they are going out which ensures privacy is respected. Residents were observed taking part in activities within the home and talking openly together about plans for individual activities in the community. Care plans detail the individual life style choices of each resident. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 10 West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 15 and 17 Residents are supported to maintain and develop personal relationships with other residents and family members within the home and wider community. The home provides a varied balanced, nutritious diet for residents. EVIDENCE: Residents told the inspector that they keep contact with family either through direct contact or with support from staff/community Social Workers. On the day of inspection one resident was planning to visit family for the weekend. Another had just received a postcard from a family friend, and one resident was observed meeting a friend in the home. Residents told the Inspector that “ Its good here because we can go out when we want and meet who we want”. There is a telephone in the communal area for residents use and staff told the inspector that it is important to encourage contact with family. Residents are able to make choices about diet with a weekly menu planning meeting held each week on Wednesdays. All residents are asked about likes and dislikes and are able to contribute to the menu choice. The weekly menu provides nutritious food with alternatives available for those that want them. This was confirmed by residents through individual and a group discussion. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 12 West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 20. The systems in place for the storage and administration of medicines are not satisfactory which could put service users at risk. EVIDENCE: Wherever possible residents are supported to self - medicate and there are some residents within the home that are self - medicating. Decisions regarding the right to self - medicate are taken together with the resident and Social work/Care Co - Ordinator. However, there was no evidence of discussion or involvement with residents GPs, or of detailed risk assessments which explained how decisions were reached. Staff confirmed care plans are currently being updated to include this information. Medication for residents who require support is kept in a lockable storage cabinet in the managers office. It was evident that storage space for medication is limited. The home is planning a programme of training for staff on medication storage and administration. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22 Individuals are encouraged to be open about their feelings and concerns. The home takes any complaint seriously and acts to support and protect residents. EVIDENCE: The home has a complaints policy and does encourage residents to talk about any concerns they may have. There are two lounges within the home which are used for activities, quiet space and residents meetings. Residents told the inspector that they meet together with staff to discuss any ideas or problems whenever they need to and that they feel their views are heard. One resident told the inspector that he wanted to be more independent and that he felt able to speak to staff about this need. As a result the resident told the inspector that he was going to “get into cooking in the kitchen”, making more of his own meals with the care teams support. Staff told the inspector that it can be difficult to encourage structured group meetings as residents are involved in other activities within the local community, however, staff are available and do encourage residents to share any concerns on a one to one basis so that any support needed can be offered. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24 and 30 The home clean and provides a safe and supportive environment for residents. EVIDENCE: The home was observed to be clean but in need of decorative update, this is being planned by the home owners. Residents and staff 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 suit their needs. Residents talked about West Dean as “their home” and the inspector observed residents freely going about daily activity as they wished. The home has comfortable lounge facilities and a more formal dining and kitchen area. The home has a relaxed atmosphere which is created by residents with staff support. it was evident that residents had confidence and felt safe both within and outside the home. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The care team are able to use training provided to support residents within the home and in the community. EVIDENCE: Staff files provided evidence of induction and training in order to meet the needs of residents. All staff have received training in adult protection and the inspector saw evidence of wider training on profiles. The home supports the training needs of staff and is planning to update this in order to provide team training on the handling of medicines. The care team has a wide range of experience suited to understanding the needs of residents. Discussion with two staff members provided evidence of an understanding of the needs of each resident and staff have good relationships with community social work teams who offer additional support for each resident. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/A Standard not inspected on this occasion. EVIDENCE: West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 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 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 4 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Dean Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 19 none 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 YA26.2 Regulation 13.2 Requirement Records of all activity relating to the handling, safekeeping, safe administration and disposal of all medicines must be kept, maintained and updated appropriately on care plans and risk assessments to include contacts with doctors and instructions about changes to individual medication. The home must provide lockable storage for residents who are self medicating and a detailed risk assessment needs to be included on all care plans for residents who self medicate. The staff team must have updated training in the handling and administartion of medicines. Timescale for action December 2005 2. YA35.6 18(1)c(i) December 2005 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 24.11 Good Practice Recommendations The home would benefit from a fire safety officer assessment. This was discussed with personell officer C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 20 West Dean 2. 3. 20.6 20.12 Jayne Crossley who agreed to action. The staff team would benefit from access to information sources on medicines e.g recent BNF. Advice should be sought from the contracted Pharmasist on developing safe procedures for medicines e.g for dispensing occaisional doses of medicines required when residents are away from the home. West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI West Dean C53 C04 S2396 West Dean V243107 090805 Stage 4.doc Version 1.40 Page 22 - 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. 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