Inspection on 06/03/06 for West House

This inspection was carried out on 6th March 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

West House 08/12/09

West House 30/06/09

West House 22/09/08

West House 25/09/07

West House 03/10/06

West House 06/10/05

West House 30/03/05

West House 23/11/04

West House 31/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE West House 11 St Vincents Road Westcliff On Sea Essex SS0 7PP Lead Inspector Pauline Marshall Unannounced Inspection 6th March 2006 09:15 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 West House DS0000015565.V283462.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. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West House Address 11 St Vincents Road Westcliff On Sea Essex SS0 7PP 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) 01702 339883 01702 346518 www.westhousenursinghome.co.uk Rootcroft Limited Mrs Helen Chitiga Care Home 25 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (25), Terminally ill (2) of places West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Terminal illness category can include persons of 55 years and older. The Home may provide care for one resident under the age of 65 years whose name is known to the Commission. 6th October 2005 Date of last inspection Brief Description of the Service: West house is an established care home that is registered for twenty-five older people. Of the twenty-five beds available, eight may be used for people with dementia and two may be used for terminal illness. West House also caters for residents requiring nursing care. Although the home mainly accommodates residents of the Jewish faith, this is not exclusively the case and residents with other faiths (or no faith) are also accommodated. The home consists of a traditional residential property, which has been modified and extended to meet the needs of older people. The shaft lift and stair lift gives access to all three floors where accommodation and communal area are situated. The home has thirteen single and six double bedrooms, many of which include en-suite facilities. The access to one of the bedrooms is via sloped flooring; there are adequate handrails around the corridor areas where these bedrooms are located, one bedroom is accessed via a small number of steps. The patio area is accessed from the conservatory and is laid out with tables and chairs; it overlooks a grassed area of the garden. The garden is accessible via a ramp and has a further seating area; it is nicely laid out with shrubs and flowers in the summer. The home is situated close to local shops and amenities and is within easy reach of the main shopping area; the seafront and local theatre are also nearby. There is a limited amount of parking to the front of the home. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that lasted for 6 hours 25 minutes and twenty-one of the thirty-eight standards were inspected. The process included discussions with the director, the manager, five staff, seven residents, four visiting relatives and friends and two visiting professionals. A random selection of staff and residents’ files and a sample of policies and procedures were examined. A tour of the building and the surrounding grounds was including in this inspection. The Home’s email address is Westhouse-Nursing-Home@whnh.co.uk. This information will automatically be included within the Service Information section of the next report. What the service does well: What has improved since the last inspection? What they could do better: The medication procedure and practice needs to be reviewed and all medication records must be accurately completed. More community activities should be organised to meet individual residents needs. More care staff should undertake NVQ2 training to ensure that they are competent in their work. Recruitment practices must meet all the requirements of legislation; a robust recruitment practice will benefit the home, its staff and its residents. West House DS0000015565.V283462.R01.S.doc Version 5.1 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 House DS0000015565.V283462.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Prospective residents and their families have sufficient information to enable them to make an informed choice about the home. A written contract and statement of terms and conditions are provided for each resident. The home has a thorough admission process and meets the needs of its residents. EVIDENCE: The statement of Purpose and Service User Guide were updated in November 2005 and now meet all the requirements of Regulation 4. Each resident has been issued with a contract that clearly sets out their terms and conditions of their residency. A pre-admission assessment is carried out by the manager and is recorded on the form entitled care plan 1. Cultural needs are assessed as part of the pre-admission assessment process and any specialists’ services are obtained where needed. Staff training files examined showed evidence of specialist training which included dementia, fall prevention, pressure area care, diabetes and nutritional needs. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 9 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, 9, 10, 11 The new care plan format sets out the residents’ health, personal and social cares needs. Medication procedures are not being followed consistently. Residents feel they are treated with respect and their privacy upheld and their wishes on terminal illness and death are sought and recorded. EVIDENCE: The home is in the process of developing a new care plan format, which gives staff clear instructions. The director and manager are working together on improving the care plans and once agreed with staff, the manager will sign them off. The new format has provision for staff to carry out regular monthly reviews; the care plan can easily be updated to reflect any changing needs. The home is currently holding too much medication; the manager said that she would be undertaking an audit of all medication that is held in stock and return all that is not required. Of the three medication records inspected, errors or omissions were found on each one. There were no PRN (as and when) medication protocols in place and codes were not always used when medication was refused or not needed. The medication order record showed that one particular medication was ordered but none received; the MARS (medication administration record) showed that it had been administered. The manager said this was from old stock, this was not reflected in the records. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 10 The home must adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. The director downloaded an up to date copy of the Royal Pharmaceutical Society of Great Britain’s Administration of Medication in Care Home, to share with staff. All shared rooms had adequate screening to ensure residents privacy and dignity whilst personal care is being carried out. The manager said that most residents open their own mail, those that are not able to usually have their relatives’ assistance. The manager said that should a resident require staff to assist them, the mail would be opened in the presence of the resident and read to them; residents spoken with confirmed this. The home has a cordless phone that is used by residents for making personal calls; one resident has their own personal phone in their bedroom. The home provides a visitors room to enable residents to see their visitors in privacy, if they do not want to use their bedroom. Residents’ wishes on terminal illness and death are sought and recorded at the initial assessment wherever possible; the information will be added to the new care plan format. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 11 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, 15 The home offers a range of activities but more needed in the local community. Residents receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: The home does not have a set activities programme. Residents spoken with said that they played cards, bingo, music, and reminiscence sessions and have singsongs; they also told of the regular visits by the musician that they said was most enjoyable. The manager and director spoke about the visits to local pubs and the seafront that had occurred in the summer and that there are plans to do this again in the warmer weather. Two residents spoken with said they would like a mini-bus so they could go out more in the summer and that they would be happy to go for a drive to the seafront and buy a Rossi ice cream or have a cup of coffee. The manager said that in addition to records of these activities being kept on individual care files, the home kept an activities book last year but was unable to locate it. The manager said that she would start a new activities book for this year. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 12 Residents spoken with said the food at the home is excellent and that they get three courses. The dining area is spacious and clean and overlooks the garden; some residents preferred to eat their meal in the lounge area. The food was well presented in served in sufficient quantities. Visitors spoken with commented on the quality and the quantity of the food served. West House DS0000015565.V283462.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): 17 Residents’ legal rights are protected. EVIDENCE: South East Essex Advocacy Service for Older People visit the home and a volunteer visitor was spoken with on the day of the inspection; he felt that the home is very good and people always appeared happy. The manager said that she provides residents with a leaflet on advocacy as part of the admission process. All residents are registered to vote; however the manager said that most do not choose to do so. West House DS0000015565.V283462.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): 19, 26 Residents live in a safe, well-maintained and clean environment. EVIDENCE: The home is well maintained and there is a planned maintenance programme; new flooring has been supplied to the ground floor hallways and the first floor bathroom. One bedroom has been completely refurbished and all rooms on the first floor have had replacement wardrobes, several bedrooms have been redecorated. The director said that any maintenance jobs identified were carried out on an as and when required basis. The furniture and furnishings around the home are of a good standard. There is a CCTV camera that monitors the front entrance. The home was found to be clean, pleasant and hygienic on the day of the inspection. A visitor spoken with said that he visited at different times of the day and that he always found the home clean and pleasant and welcoming. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 15 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, 28, 29, 30 The rota indicated sufficient staff on each shift to meet the residents’ needs. More staff needs to undertake NVQ training to ensure residents are in safe hands at all times. The homes recruitment practice does not protect and support residents. Staff are well trained. EVIDENCE: More staff has recently been employed; therefore less staff is working long days. One staff member works three long days a week but this is their preference as they live some distance from the home. The staff rota reflected the staff that were on duty and met the requirements that were previously set. There are eight qualified nurses employed at the home and one is on duty at all times. The home employs nineteen care assistants, two have completed their NVQ and two are in the process and one further care assistant is undertaking the access to nursing course. The home needs to ensure that more of the staff team undertake NVQ training. All staff are given a copy of the General Social care Councils ‘Code of Practice’ with their terms and conditions (contract of employment). Three staff files were examined; two were for employees recruited within the last month. Out of the three files examined, none contained evidence of the fitness of the worker to do the work. Two files did not have evidence of the workers right to work, no references, no photograph of the employee and no identification. One file contained two references that were identical in their content from the same West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 16 address but from different referees. The home should be satisfied that all references are authentic. The three application forms were not fully completed; therefore gaps in employment could not be explored. All files contained a current CRB. The home must ensure that robust recruitment procedures are in place and that records are maintained. All new staff receives TOPSS induction training that is provided by Essex Nursing Services and although new staff have induction to the home in the first week of employment, this is not recorded. The director has recently developed a staff handbook that will be given to all existing staff in addition to new staff. All mandatory training is carried out as part of the TOPSS induction; specialist training is identified according to the resident needs. Staff spoken with said that the training provided by the home is good. West House DS0000015565.V283462.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): 35, 36, 37, 38 Residents’ financial interests are safeguarded. Staff are appropriately supervised. The homes record keeping has improved and continues to do so. The health, safety and welfare of residents and staff are protected. EVIDENCE: The home holds cash for two residents only; records of transactions and the balance of the cash were examined and were found to be correct. Regular charges for hairdressing were without a receipt, it was advised that a receipt should be obtained and stored with each individual’s transaction records. Supervisions are held regularly but do not include all the areas required in the standards. The manager said that she would revise the format of the supervision document to meet the requirements. The benefits of regular staff meetings were discussed with the manager. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 18 The home is in the process of reviewing many of the documents it uses for record keeping; the new director has improved the care plan format and the staff handbook. The new accident book is now in use and all accidents accurately recorded in it. Safety certificates were inspected and were all up to date, regular checks were made on fire equipment. The manager said that fire drills are carried out regularly, however there was no evidence of this. The fire risk assessment needs to be reviewed. West House DS0000015565.V283462.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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 3 3 West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 01/04/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This is a repeat requirement. 2. OP29 19(1)(b) (i)(c)Sch 2 The registered person shall not employee a person to work at the care home unless he has obtained all the information in Schedule 2 and he is satisfied on reasonable grounds as to the authenticity of any references. This is a repeat requirement. 01/04/06 Requirement West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 21 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. 3. Refer to Standard OP12 OP28 OP38 Good Practice Recommendations The home should ensure that residents have the opportunity to exercise their choice in relation to leisure and social activities within the local community. The home need to ensure that 50 of care staff undertakes NVQ training at a minimum of level 2 in care. The home should review its fire risk assessment and ensure that regular fire drills are carried out and the outcome recorded. West House DS0000015565.V283462.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 House DS0000015565.V283462.R01.S.doc Version 5.1 Page 23 - 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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