Inspection on 25/01/07 for West Haven

This inspection was carried out on 25th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Haven 22/11/06

West Haven 23/11/05

West Haven 22/04/05

West Haven 08/09/04

West Haven 15/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 West Haven 146 Huddersfield Road Dewsbury West Yorkshire WF13 2RW Lead Inspector Bronwynn Bennett Unannounced Inspection 25th January 2007 09:45 West Haven DS0000026332.V328866.R01.S.doc Version 5.2 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 Haven DS0000026332.V328866.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 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 Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Haven Address 146 Huddersfield Road Dewsbury West Yorkshire WF13 2RW 01924 461720 01924 461720 westhaven146@tiscali.co.uk 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) Catholic Care (Diocese of Leeds) Mr Peter Simmons Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. When the person with LD(E) is no longer living at the home, the Category of Registration reverts to LD for 7 persons of either sex. 22nd November 2006 Date of last inspection Brief Description of the Service: Westhaven is a home for up to 7 adults who have learning disabilities. The home is owned by Catholic Care. It is located within close proximity to public transport links and local shops and is a short walk from the centre of Dewsbury with all its amenities. The home has ample communal space where people who receive services are able to spend time, including three lounges and a dining room. The home has a large, private garden, providing a safe environment for people living at Westhaven The provider informed the Commission for Social Care Inspection on 21.10.06 that the fees are £597.93 per week. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by two inspectors. The inspectors arrived at the home at 9.45am and left at 12.50pm. During this visit the inspector spoke to some service users, some of the staff and the acting manager Ms Julie Wade. The inspector read records of people’s care, staff records, looked at how medicines are given and looked at the accommodation available in the home. There were six service users living at the home on the day of this visit. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the care provider, and a pre inspection questionnaire completed by the acting manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: What has improved since the last inspection? Since the last visit by the CSCI the organisation has appointed Ms Julie Wade as the acting manager and are recruiting a care worker to ensure the staffing levels meet the needs of the service. The acting manager and the staff have worked hard to address issues relating to the care records for service users. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 6 There have been some improvement works to the environment since the last visit by the CSCI. 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. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 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 Haven DS0000026332.V328866.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ individual needs and aspirations are assessed prior to admission. EVIDENCE: The home is currently working towards a planned admission for a service user to the home. The process of admission to the home was discussed with the deputy manager of the home. The social services community care assessment and associated records was seen. No service user is admitted to the home without a full assessment and regular visits where they are introduced to existing service users living at the home. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users assessed and personal needs and goals are recorded in their plan of care. The support required by service users to make decisions and the risks taken as part of an independent lifestyle are appropriately recorded in care records. EVIDENCE: Two service users’ records were examined during this visit. The information kept in service users records has improved since the last visit by the CSCI. And both records looked at held an up to date plan of care. The care records are person centred with specialist interventions and individual personal care needs recorded. There was evidence of regular reviews held for service users. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 10 The staff at the home have worked hard to improve the standard of records relating to service users. The staff were seen interacting well with the service users respecting their right to make decisions. Service users are supported to handle their own finances and lockable facilities are provided for this purpose. The level of support required by and individual decisions made by service users was seen recorded in the care records looked at. Service users are supported to take risks as part of their chosen lifestyle, and up to date, detailed and reviewed risk assessments were seen. Again this is good practice and shows an improvement since the last visit by the CSCI. The information recorded was clear, easy to follow and outlines the level of risk and the measures in place to minimise the risk and any associated hazards. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The service users are supported to be part of the local community and take part in appropriate activities. Service users are supported to maintain relationships with family and friends. Generally, the service users’ rights are respected and individuals’ choice and independence is promoted. EVIDENCE: One service user is in paid employment and each individual is supported to access training should they wish to do. The opportunity to pursue interests, hobbies and develop skills is supported by the staff at the home. The service users were seen being supported by the staff in their chosen activity throughout the day. Activities are recorded in the daily records kept. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 12 Service users are supported to be part of the local community and go out independently if they wish. Activities participated in include the church, gym, social education centre and shopping. The staff have worked well in helping service users access activities they can take part in. This is good practice. There was information recorded in the individual records regarding the service users’ links with the local community. The service users hold monthly meetings were they are supported to share their views about how the home is run. Individual relationships with family and friends are supported. And service users spoken with said they are able to see their family and friends when they wish. One of the staff supports a service user in writing letters to relatives. Some individuals have chosen to use mobile phones in order to keep regular contact with their friends and relatives. There was good interaction and relationships noted between the service users and the staff. The staff were observed treating individual’s in a respectful and dignified manner throughout this visit. Some individuals clean there own rooms and launder their own clothing independently or with support of staff. Service users are supported to plan the home’s main menu and choose a day to plan a meal. In addition to choosing food, the service users are active in shopping for food and in the preparation of meals. During this visit the service users went out shopping for the home and were planning to assist the staff to make the evening meal. As meals are generally planned from cookery books there tends to be little use of processed foods and ready meals. This is good practice and generally supports individuals to choose a healthy diet. Alternative meals are provided and specialist diets are catered for by the home. One person is currently being encouraged to eat a diet that has a high fruit and vegetable content. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in their preferred way and generally the individuals health care needs are met. The home’s medication policy and procedure protects the service users. EVIDENCE: The service users choices of how they receive personal care and other related activities were seen recorded in the individual care records. A named key worker was identified in the individual records looked at and the service users spoken with said they knew their key worker. There was information available to show that service users have a health care plan. Individuals are supported to access NHS healthcare facilities and access visits to their GP. Suitable scales have been purchased in order that service users weights can be monitored. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 14 The home’s medication system was audited and the medication for three service users was checked and was accurate. The acting manager has addressed the matter of “homely remedies” kept by the home. The GP’s consent regarding homely remedies is now recorded in individual records. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users feel that their views are listened to and acted upon, and they are protected from abuse. EVIDENCE: A service user spoken to during this visit said they knew who to speak with if they had any concerns or wished to complain. The home has a complaints policy and procedure that is also available in suitable formats service users. There has been one complaint made in the home since the last visit by the CSCI. A record is kept of all issues raised, including complaints, complete with the details of any investigation, action taken and the outcome. All staff have received adult protection training and are able to demonstrate a good understanding of the required actions that must be taken should there be any allegations of abuse. The financial records for three service users was checked and correct. Individuals are supported to manage their own finances should they wish to do so. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean but action must be taken to ensure the home provides a safe and well-maintained environment. EVIDENCE: As part of this visit a tour of the home was carried out and the home was generally clean and odour free. The lounge areas are comfortable and homely and a service user’s room was personalised by the individual. The dining room carpet is showing signs of wear and tear and consideration should be given by the organisation for it to be replaced. West Yorkshire Fire service visited the home in December 2006. Not all the required fire works has yet been completed. The acting manager said all the required fire works were planned. This must be addressed in order to ensure the health and safety of the service users and the staff. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 17 The deputy manager said the fire risk assessment had been reviewed and up to date and some fire safety issues had been addressed, such as interior doors held open by door wedges. However, the request for a copy of the up to date fire risk assessment, and a plan, complete with timescales for fire works has not yet been received by the CSCI. The organisation must send the required information to the CSCI as a requested. A tour of the home was carried out. During this visit some work was being carried out in the identified bathroom. Some health and safety works have been completed. Window restrictors have been fitted to the identified service users windows and there is no longer an exposed wire in the wall. Some of the exterior windows are showing signs of wear and tear. And the wood in one of the frames was soft and deteriorating. The deputy manager said that a bedroom carpet had been replaced with laminate flooring. There has been some repainting to some areas of the home. However, there is no planned maintenance in the home and the organisation should implement and ongoing programme of maintenance and renewal of the premises. Communal towels are still present in the toilets and bathrooms. This poses a potential cross infection risk to the service users. Suitable paper towel dispenses must be fitted to communal areas. The laundry facilities were seen and were well organised and potentially harmful substances are kept in a locked (COSHH) cupboard. The organisation must undertake a survey of the premises. The necessary repairs must be carried out to ensure the home is in a good state of repair externally and internally. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to support the service users. The organisation is addressing the training needs of staff to ensure individual service users are fully supported. The home’s recruitment policy and procedure is sufficiently robust to protect the service users. EVIDENCE: The service users continue to enjoy good relationships with the staff. The service users spoken with during this visit said they liked the staff working at the home and felt well cared for. During the visit the individuals and the staff were observed interacting well. The records for three staff working in the home were audited and held the required information. The organisation is currently recruiting staff to ensure there are sufficient numbers of staff employed at the home. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 19 Staff receive induction training and have completed LDAF (Learning Disability Award Framework) accredited training. Six of the care staff have achieved NVQ (National Vocational Qualification) level 2 or above. The deputy manager said that the majority of staff had undertaken training in adult protection, infection control, health and safety, food hygiene, oral hygiene and movement and handling. The remainder of staff have been booked on to the required training. The organisation should ensure there is a training and development plan. Staff should have five paid training and development days (pro rata) per year. One of the staff has completed training in dementia care and the acting manager said that training is planned for all staff in care of the elderly. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The current management arrangements ensure service users benefit from a home a well run home. Generally, the home is run in the best interests of the service users. Greater care must be taken to ensure the health, safety and welfare of the service users, and the staff, is sufficiently promoted and protected. EVIDENCE: The registered manager is currently taking extended leave from the home. The organisation have appointed Ms Julie Wade as the home’s deputy manager. Ms Wade should be commended for her hard work in addressing some of the issues raised during the last visit by the CSCI to West Haven. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 21 There is some quality monitoring carried out at the home. There are monthly staff and service user meetings. In addition, there are quality visits made by a representative of the organisation. Service users are supported during meetings to air their views and make decisions about what happens in the home. Service users are currently planning trips out and a birthday celebration. The fire records were checked and the homes fire system and emergency lighting is tested weekly with the appropriate records being kept. There are fire drills carried out at the home that service users are involved in. The staff have not yet undertaken fire safety training. However, the deputy manager said that this training is booked for staff to complete by February 2007. All staff must complete fire safety training and have six monthly updates in this training. A requirement is carried forward in this report regarding this matter. Concerns were raised regarding the cellar area of the home. Paint and potentially hazardous substances were stored in this area that service users have access. This was discussed with the acting manager who said she would take action to remove the hazardous substances stored. In addition, the inspector noted stagnant water from an unknown source and a possible hazardous substance in the cellar. This was discussed with acting manager. This matter is to be investigated by the relevant health and safety department. Until the organisation is satisfied that the cellar area is safe there must be an up to date risk assessment put in place. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 23 Yes 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 YA24 Regulation 23.4 Requirement The registered person must complete the required fire safety works as requested by West Yorkshire Fire Service. A copy of the up to date fire risk assessment, and a plan, complete with timescales for fire works must be sent the CSCI by the date stated opposite. Previous Timescale of 22/12/06 not met. 2. YA24 23.1 & 23.2 The organisation must undertake 25/03/07 a survey of the premises. The necessary repairs must be carried out to ensure the home is in a good state of repair externally and internally. The windows in the home must be surveyed and repaired or replaced as required. 3. YA30 13.3 The registered person must make suitable arrangements to prevent infection and the spread in infection at the care home. 25/03/07 Timescale for action 25/03/07 West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 24 Paper towels should be fitted to communal areas accessed by the service users and the staff. Previous Timescale of 22/12/06 not met. 4. YA42 23 (d) The registered person must make arrangements for people working in the care home to receive suitable training in fire prevention. Such training must be updated at six monthly intervals. Previous Timescale of 22/01/07 not met. 5. YA42 23 and 13.4 The registered person must ensure the home is of sound construction and kept in a good state of repair both internally and externally. And ensure any unnecessary risks to service users are identified and so far as possible eliminated. Until the organisation is satisfied that the cellar area is safe there must be an up to date risk assessment must be put in place. 25/03/07 25/03/07 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. 2. Refer to Standard YA24 YA35 Good Practice Recommendations The organisation should consider replacing the dining room carpet. The organisation should develop and staff training and development plan. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 25 3. YA39 The organisation should develop quality assurance and quality monitoring systems. The results of surveys should be published and made available to service users, family and friends, and any other interested parties. West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square (South) Leeds LS1 2ND 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 West Haven DS0000026332.V328866.R01.S.doc Version 5.2 Page 27 - 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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