Inspection on 04/12/07 for West House Care Home

This inspection was carried out on 4th December 2007.

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 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 Care Home 26/11/08

West House Care Home 21/06/06

West House Care Home 08/02/06

West House Care Home 28/09/05

West House Care Home 01/03/05

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE West House Care Home Waldridge Road Chester Le Street Durham DH2 3AA Lead Inspector Tanya Newton Unannounced Inspection 13:00 4 December 2007 th 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 Care Home DS0000062946.V355287.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 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 Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West House Care Home Address Waldridge Road Chester Le Street Durham DH2 3AA 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) 0191 3871533 0191 3873968 Roundview Properties Ltd Mrs Barbara Sally Stubbs Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 Brief Description of the Service: West House is a home owned by Roundview properties Ltd. It is registered to provide nursing and residential care for up to 30 older persons. The home offers single and double room accommodation, with communal sitting/dining areas. Bathrooms are located throughout the home, some of which have aids to support people during personal care. West House is situated in Chester-le street, a town near to Durham and Newcastle. Mrs Barbara Stubbs manages the home. Fees within the home range from £372 to £392. Fees do not include hairdressing and chiropody. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Newton and Mrs Lowther carried out the inspection on the 4th December between the hours of 1pm and 4:30pm. A tour of the building was taken and the inspectors spent time talking to people living and working at the home, as well as visitors and staff. Many of the comments received during the inspection have been included within the report. The provider of the home has completed an annual assessment, which provides the Commission with information about the home prior to us visiting. What the service does well: What has improved since the last inspection? What they could do better: Assessments and care plans need to contain more detailed information, so that people’s health needs can be monitored. Calogen must be dated on opening and stored in the fridge. The drugs fridge needs to be maintained at a safe temperature. Eye drops must be dated when opened. All complaints and concerns should be recorded with any action taken by the home. The carpets in the corridors and lounges need to be replaced. New bedding, quilts and curtains are still required in some areas. New chairs are required in lounges. A new bath panel is required to the bath on the bottom corridor. Shortfalls in training must be addressed so that all staff have the skills required to meet the physical and emotional needs of the people accommodated. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 6 The owner of the home needs a clear plan, which sets out what expenditure will be made to improve the premises and enable resources required for staff training. The manager needs some budgetary control in order that the home can be ran appropriately. The Regulation 26 visits must be carried out by the provider each month and a report must be held in the home. An up to date electrical wiring certificate must also be available, a copy of this should be sent to the Commission following the inspection. The temperature in the treatment room should be monitored to ensure it remains at 25 degrees or below. 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 House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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 Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The assessments are at varying levels and generally require some improvement. EVIDENCE: Two assessments were viewed. The assessments were at varying levels. One contained detailed information and the other contained very limited information. Neither of the assessments viewed contained an assessment from the placing authority. Assessments form the basis from which the care plan will be written. This describes how the home will meet individual needs. The home does not admit residents for intermediate care although respite (short stay) care is provided. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People’s care needs are not being sufficiently recorded. Some minor improvements are required to medication systems, however these are generally sound. People’s privacy and dignity are maintained. EVIDENCE: Care plans were looked at. Nutritional screening, falls risk assessment, pressure care and moving and handling needs are all assessed on an ongoing basis. However where a problem has been identified assessments are not always followed through with a care plan which demonstrates how that particular problem will be minimised or removed. The home has colour coded manual handling assessments which support staff in immediately identifying problems. Those viewed had not been completed in colour making them fairly meaningless for staff. Although social care plans were in place, those viewed were blank. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 10 Although there were gaps in the recording of information, feedback from people living at the home and their relatives was positive. Comments included “The staff go beyond care here for residents and relatives, they look after us all”, “I love it here and get well looked after, everything that I need is here” and “The care seems very good here, I am satisfied”. Medication records were up to date for each person living at West House and medicines received, administered and disposed of are recorded. A qualified nurse gives out all medication. Calogen must be dated on opening and stored in the fridge. The drugs fridge is running at a consistently high temperature, it was checked three times during the inspection and was running at 12 degrees. Some of the eye drops had not been dated when opened, and one person’s medication was in a pot although staff could not say why. The home does carry out regular audits of medication to check that systems are running smoothly. There are no people who are able to administer their own medication at present. The temperature in the treatment room should be monitored to ensure it remains at 25 degrees or below. The staff said that particular attention is given to supporting people’s privacy and dignity when delivering personal care. All care is carried out in private and staff knock before entering people’s rooms. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Activities have improved, but still do not satisfy all of the people accommodated and are not being recorded in people’s care plans. People are able to see their relatives and friends. Comments about the food were positive and people said that they were able to make choices in most aspects of daily living. EVIDENCE: The comments regarding activities were mixed. The home does not have an activities co-ordinator although the post has been advertised repeatedly. Comments included “I sit and watch TV, sometimes there is a singer, I am quite happy, my son takes me out”, “socially, there’s not much, we are having a party for Christmas and entertainment” and “activities seem to be personal and more on a one to one”. Social assessments were not being completed within care plans. Staff said that a lot of people chose not to be involved in activities and that it was hard to get people interested. The manager said that she had to fund raise for all entertainment and said that this was often difficult. She said that more activities were available and staff confirmed this. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 12 The home has open visiting arrangements and people know that they can entertain their visitors in their own room. If they prefer they can use community areas of the home to talk to visitors. People were asked if they felt that they could make choices, their responses included “I can choose when to go to bed” and “I come and go when I want and choose what I want to eat, everything is here that I need I only have to ask”. Comments about the food were positive and included “ the food has improved, we get two choices and can have a drink at any time” and “the meals are good”. One visitor said, “The food could be better, there is not much variation”. The owner regularly purchases individual items for people to ensure that individual choices are catered for and staff said that the chef would make something else if people don’t want what is on the menu. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Policies and procedures in this area support staff and protect people. All complaints should be recorded in the complaints book, along with any action taken. EVIDENCE: There are adequate written policies and procedures in place to deal with complaints and care staff said they were aware of these. There is a complaints book next to the entrance foyer. Two concerns, which had been raised with the home as well as the commission, had not been recorded. The manager gave examples of how both of these issues had been dealt with. The manager was advised to record all concerns/complaints and to record any outcome of any investigation and/or any action taken. Staff are trained to recognise and prevent abuse. The home has a clear adult protection procedure which links with the local authority procedure for safeguarding adults. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in whistle blowing (telling someone) if there was a problem. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Refurbishment of the home continues. However, a detailed plan with timescales outlining how and when the rest of the refurbishment will take place is required. EVIDENCE: The home is slowly undergoing a programme of redecoration. Since the last inspection, chairs have been purchased for the dining room and new carpets have been laid in the hall, dining room and stairway. Bedrooms, which were previously used as double rooms, have been decorated and made into large single rooms. New carpets have been fitted in these rooms. The chairs in the lounges are very badly stained and some were smelly. These need to be replaced. New carpets are still required in the lounges and corridors of the home. Domestic staff work hard to maintain standards of West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 15 cleanliness within the home but some items are at the end of their life and require replacement. The bath panel to the bath on the ground floor corridor was badly cracked. This must be replaced as it poses a risk to the people using it. Some new bedding, quilts and curtains have been purchased. The manager said that there was no budget for these items so it was difficult to replace them. The home now operates a non-smoking policy throughout the home. Comments from visitors and staff included “the home could do with a face lift” and “the only improvement needed here is to the environment”. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Staffing numbers in the main are sufficient to meet people’s needs. Shortfalls in training must be addressed so that all staff have the skills required to meet the physical and emotional needs of the people accommodated. Recruitment systems were generally sound and protected people. EVIDENCE: There is a registered nurse on duty at all times in West House and there are four carers on duty on a morning and three on an afternoon. The manager’s hours are in addition to these. People using the service are generally satisfied with the care they receive, but there are times when they may need to wait a short time for staff support and attention. Staff said that the staffing levels were sufficient to care for people. Staff training was not up to date. Six of the thirteen staff need first aid and twelve staff require manual handling, the majority of staff also require food hygiene. Six staff require training in the protection of vulnerable adults (POVA) and the majority had not attended infection control or health and safety training. Shortfalls in training must be addressed so that all staff have the skills required to meet the physical and emotional needs of the people accommodated. Ten of the thirteen care staff had an NVQ at level 2 or above. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 17 Some staff had recently had training in Equality and Diversity. Three staff files were checked during the inspection, some of the records for staff employed at the home for a number of years do not contain two references, all staff have been police checked. New staff are employed appropriately with two references and a police check being sought prior to them starting employment. The manager should follow up references by telephone to ensure that they are reliable. People living at West House were complimentary about staff and commented “staff are ok, I am satisfied” and “the staff are very good”. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The owner of the home needs a clear plan, which sets out what expenditure will be made to improve the premises and staff training. The manager needs some budgetary control in order that the home can be ran appropriately. Quality assurance systems have improved although the Regulation 26 visits are not being kept up to date. Health and Safety systems in the main were good and protect people. EVIDENCE: The manager has the required qualifications and experience to run the home. The manager does not hold a budget and therefore has only limited management capabilities within the service. Comments from staff regarding the management were positive and included “the manager and nurses are very good” and “I could approach the manager if West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 19 needed and would tell her if I saw any problem”. Morale is high and there is a good rapport between the staff and the people accomodated. This was observed throughout the inspection. Feedback is gained through staff meetings, user meetings and day-to-day contact with those living within West House and their relatives. Questionnaires have also been given to relatives. The owner carries out regular visits to the home these must be formalised. A report must be written regarding these visits on a monthly basis. This information helps to improve the service being provided to people living at the home. A random sample of people’s monies were audited. Systems were sound and were audited reguarly. Regular health and safety checks are carried out, some of these records were looked at during the inspection. The temperature in the treatment room should be monitored to ensure it remains at 25 degrees or below. A portable door guard has been purchased which can be fitted if someone would like their door to remain open. The electrical wiring certificate for the premises was dated 2004, an up to date certificate is required. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 20 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 14 Requirement Each person must be provided with a comprehensive assessment before being admitted to the home. People’s health and personal care needs must be fully recorded within their plan of care. Where risks are identified these must be minimised. Calogen must be dated on opening and stored in the fridge. The drugs fridge needs to be maintained at a safe temperature. Eye drops must be dated when opened. The carpets in the corridors and lounges need to be replaced. New bedding, quilts and curtains are still required in some areas. Previous requirement of 30/11/06 met in part. New chairs are required in lounges. The registered person must ensure that at all times suitably qualified staff are working at the home. Staff must receive DS0000062946.V355287.R01.S.doc Timescale for action 31/01/08 2. OP7 15 31/01/08 3. OP9 13(2) 30/12/07 4. OP19 23(2) b 31/03/08 5. OP27 18(1) 31/03/08 West House Care Home Version 5.2 Page 22 6. OP30 18(1) 7. OP31 25(1) 8. OP33 26 training, which is appropriate to the work that they perform. The registered person must ensure that there is a staff training and development programme. All staff should receive a minimum of 3 paid training days each year. The owner of the home needs a clear plan, which sets out what expenditure will be allocated to improve the premises and what resources will be allocated for staff training. The manager needs some budgetary control in order that the home can be ran appropriately. Regulation 26 visits must be carried out and a report on these visits be provided within the home. 31/03/08 31/01/08 31/12/07 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. 3. Refer to Standard OP12 OP9 OP16 Good Practice Recommendations Social needs should be recorded in the care plan. The home should continue to develop social activities with the involvement of people living at the home. The temperature in the treatment room should be monitored to ensure it remains at 25 degrees or below. Complaints and concerns, which are made to the home, should be recorded, along with any action taken. West House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 House Care Home DS0000062946.V355287.R01.S.doc Version 5.2 Page 24 - 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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