Inspection on 06/10/05 for West House

This inspection was carried out on 6th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 06/03/06

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. Vincent Road Westcliff-on-Sea Essex SS0 7PP Lead Inspector Mr Ron Reeves Second Inspector Pauline Marshall Unannounced Thursday 6 October 2005 th 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 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 I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service West House Address 11 St. Vincent Road Westcliff-on-Sea Essex SS0 7PP 01702 339883 01702 346518 westhouse.nursing@bt.com Rootcroft Limited 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) Mrs Helen Chitiga CRH Care Home 24 Category(ies) of DE Dementia (6) registration, with number OP Old Age (24) of places TI Terminally ill (2) West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of service users not to exceed 24 at any one time. 2. Total number of service users with terminal illness not to exceed 2. 3. Total number of service users with dementia (over 65) not to exceed 6. 4. Terminally ill to persons over the age of 55. 5. Home may provide care to one resident aged under 65 year of age whose name is known to the Commission. Date of last inspection 30th March 2005 Brief Description of the Service: West house is an established care home for no more than 24 older people, which includes registration for a maximum of 6 service users with dementia two terminal illness beds. West House also caters for those service users requiring nursing. Although the home mainly accommodates service users of the Jewish faith, this is not exclusively the case and service users with other faiths (or no faith) are also accommodated. The home consists of a traditional residential property, which has been modified and extended to accommodate services users. The resident’s accommodation and communal areas are situated on three floors, with assisted access provided by the provision of both passenger and stair lifts supplying all three-floor levels. Both single and two person rooms are provided, many of which include en-suite facilities. One bedroom requires access via a small number of steps. Some bedrooms require access to be gained via sloped flooring within the corridors. Similarly a ramp is provided for access to the grounds/gardens to the rear of the premises. Some of the service users bedrooms are in need of redecoration. The home is situated within relatively close proximity to local and main shopping. Other civic amenities such as the theatre and seafront are also in the vicinity West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection which lasted eight hours. During the inspection the inspectors spoke with nine residents, three visitors, the senior nurse on duty, four staff and the proprietors were available for discussion during the morning. The inspection also included a tour of the building examination of a sample of care plans and records. The home’s manager was not on duty. What the service does well: What has improved since the last inspection? 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. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 7 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 standard(s) 1,2,5 The home’s Statement of Purpose and Service Users Guide are inadequate and does not provide sufficient information for prospective residents to be clear about the services the home provides to meet their needs. EVIDENCE: Copies of the home’s Statement of Purpose and Service Users’ Guide examined still do not meet the required regulations. Residents individual contracts were not available. Residents spoken with said their relatives found the home and visited before making a decision regarding admission. One relative, who visited several homes before making a decision said he chose this home because of the quality of care. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 8 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 standard(s) 7-10 Residents are well looked after in respect of their health and personal care. Further improvements are required to the home’s care plans, risk assessments daily monitoring and medication administration. EVIDENCE: Residents health and personal care needs are set out in individual care plans. However the format was inappropriate. Care plans seen were written on the form that is used for the home’s daily recording which was confusing. Care needs were not clearly identified and instructions for staff to meet these needs were not comprehensive and included generalisations. Resident’s profiles and records of G.P visits were kept separately. Risk assessments did not include why the risk assessment was required and were not fully completed. Review forms were not dated or signed. Daily recordings did not fully reflect the welfare of the resident how they spent their day and the progress of the care plan. There was no evidence to support that residents and/or that relatives were involved in the care planning process. Discussions took place and advice given with the senior nurse on duty regarding improvements required. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 9 There was evidence to show that the home ensures that residents are supported to access all the community health facilities. Medication administration recording was poor. Several omissions were noted on the Medication Administration records (MAR). Medication prescribed for specific times during the day was not given. This was basically pain relief. The senior nurse was advised to consult the G.P. to review the frequency and dosage of these medications. New or repeat medication was not booked in on the MAR sheets and liquid medication not marked with date of opening. There was no evidence to support that various creams prescribed for individual resident which are stored in residents bedrooms were administered. Residents spoken with expressed their satisfaction with the care they received and felt that staff always respect their privacy. Observations throughout the day indicated that staff treat residents in a caring and unhurried manner. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 10 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 standard(s) 13-15 Daily routines were generally flexible. Visiting arrangements were open and relaxed. The home supplied a good quality of food and provided a well balanced diet that met individual needs. EVIDENCE: Although activities were not examined in detail, residents spoken with said they do have activities and can join in when they want. On the day of the inspection, an outside entertainer sang to the residents who appeared to thoroughly enjoy it. Some of the residents said that they no longer are taken out by the home and had to rely on their relatives to take them out. This was pointed out at the last inspection. Relatives spoken with said that they can visit when they wish and are always made welcome and can always speak to the manager. The proprietor informed that she hopes to hold quarterly meetings with the relatives. Residents described the food provided by the home as “excellent”. The home employs a chef who is prepared to cook any meal to accommodate individual residents needs. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 11 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 standard(s) 16 & 18 The home has appropriate policies, procedures and practices in place for protecting residents and responding to their concerns. EVIDENCE: The home’s complaints procedure was being reviewed by the home’s business manager at the time of the inspection. No complaints have been received by the home in the previous 12 months. The home has an appropriate policy for protecting vulnerable adults and staff receive appropriate training. Staff spoken with were aware of the homes whistle blowing procedure. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 12 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 standard(s) 19-26 A safe and comfortable standard of accommodation is provided for the residents. EVIDENCE: West House is an adapted large house, which provides accommodation for residents on three floors, accessed by a passenger lift, and a staff lift. The premises are generally well maintained with an attractive garden to the rear. Furniture and furnishing are to a good standard. There is CCTV coverage to the front entrance. The proprietors informed that maintenance is carried out as and when required. Communal facilities include a large lounge diner and conservatory. Many of the bedrooms are en-suite and there are sufficient adapted toilets and bathrooms. The home has recently added two single en-suite bathrooms. Bedrooms were found to be well furnished and personalised to individual tastes, however some will require re-decoration in the near future. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 13 The proprietors informed us that there are plans to refurbish rooms when they are vacated. New carpets have been fitted to some of the corridors and stairs. Other areas are due to be recarpeted in the near future. The home was found to be generally clean and tidy throughout. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-29 Staff rotas indicated sufficient staff on each shift to meet residents needs, but this is achieved by staff working long shifts. Additional staff need to be recruited. EVIDENCE: Staff rotas indicated that agreed staffing levels of 1 nurse, 5 carers on the early shift and 1 nurse plus 4 care during the afternoon and evening. Staff on duty during the inspection matched those on duty. Staff rotas showed that many long shifts are being worked by the staff to maintain staffing levels. It is estimated that the home would need to employ a further 7 staff in order to avoid long days. Two staff files examined did not contain all the information required by legislation. Resident comments on the staff were very complimentary and all felt they were well looked after. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-33 The manager and her staff provide a high quality of care to the residents, however the standard of record keeping requires significant improvement. EVIDENCE: The manager has many years experience with the client group. She is in the process of training for NVQ 4. Staff and residents spoken with throughout the inspection felt the manager was easily approachable and supportive. The home has recently employed a business manager, he is at present reviewing the home’s policies and procedures and records. Many records in the home require reviewing and improving, some have been commented on throughout the report. There was no evidence to suggest the home is not financially viable. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 16 All staff have received training in Healthcare and Safety. The manager is an approved cascade manual handling trainer. Safety certificates were available for services and equipment apart from the electrical installation. Regular checks were carried out on the fire prevention equipment. Accidents occurring in the home are recorded in a book. Many are not signed. The senior nurse on duty was advised to purchase the official accident report book in consultation with the local environmental health officer. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 1 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 x x 2 2 West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 18 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 1 Regulation 4 Requirement The homes Statement of Purpose and service users guide must be updated to ensure they meeet the requirements of Regulation 4 schedule (1). A copy of each residents terms and conditions of residence must be available in the home. The home must ensure that each resients care plan clearly identifies their care needs and how these needs are to be met including clear risk assessments and are reviewed on a regular basis. The home must ensure that appropriate arrangements are in place to ensure the recording, safekeeping, administration and disposal of medicines into the home. The home must ensure that at all times, suitable, qualified, competenant and experienced staff are working in the home. This refers specifically to the staff working long shifts as there are insufficient staff employed. The home must ensure that robust recruitment procedures are in place and records Timescale for action 30/11/05 2. 3. 1 7 5 12 and 15 With immediate effect 30/11/05 4. 9 13(2) With immediate effect 5. 27 18 30/11/05 6. 29 17(2) Schedule (4) 30/11/05 West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 19 maintained. 7. 38 23 The home must comply with Electricity at Work Regulations. This includes a current Electrical Installation Certificate. 30/11/05 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 12 37 Good Practice Recommendations The registered person should ensure staff take out residents who wish to be taken out. The registered person should ensure the home uses the accident report format issued by the Health and Safety Executive. West House I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 I56 I06 S15565 West House V241519 061005 Stage4.doc Version 1.40 Page 21 - 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. 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