Inspection on 08/02/06 for West House Care Home

This inspection was carried out on 8th February 2006.

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 Care Home 26/11/08

West House Care Home 04/12/07

West House Care Home 21/06/06

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 Mrs Tanya Newton Unannounced Inspection 10:00a 8 February 2006 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.V261055.R01.S.doc Version 5.0 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.V261055.R01.S.doc Version 5.0 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 387 1533 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), Terminally ill (3) of places West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Terminal illness: Persons with a terminal illness (palliative care) over the age of 55 may be accommodated commensurate with the homes Statement of Purpose and function and where appropriately qualified and competent staff are provided. 28/09/05 Date of last inspection 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 service users during personal care. West House is situated in Chester-le street, a town near to Durham and Newcastle. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out between the hours of 10:00am and 3:30pm. A tour of the building was taken and some of the homes records were looked at. The manager was not on duty during the inspection so time was spent with the qualified nurse. The owner was also available for some of the inspection. Time was also spent talking to five service users, five relatives and four of the staff on duty and some of their comments are included within the body of the report. In line with current CSCI policy on Proportionality, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion were addressed in the previous visit to the home, which took place in September 2005. Issues raised in the last inspection were also examined. What the service does well: What has improved since the last inspection? A programme of decoration has commenced and the owner is keen for this to continue. Relatives would like to see this continue and made a number of positive comments about the work that has been carried out so far. Each service users is given a contract, which tells them what is included within their fees. Some of the policies had been updated. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 6 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 Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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.V261055.R01.S.doc Version 5.0 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): 2&3 Assessments are provided before admission. Only service users whose needs can be met are admitted to the home. A contract is given to service users, which tells them what the home is providing within the fees paid. EVIDENCE: Assessments include information that shows how the home will meet individual needs; they form the basis from which the care plan is written. Residents and relatives are encouraged to visit the home prior to admission. Residents are now provided with a contract, which he or she or their relative will sign. The contract states that relatives must not visit during mealtimes this information is not correct. Visitors often come to the home and have a meal with their relative. The home supports this. The contract should be amended to reflect this. The home does not admit service users who require intermediate care. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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 There is a care planning system in place, which provides staff with the information they need to satisfactorily meet service user’s needs. There is some evidence of service user’s involvement within these plans. EVIDENCE: Three care plans were viewed during the inspection, care plans were well written and provide staff with clear guidance on how to meet an individual residents needs. Discussion with staff working within the home confirmed that a high standard of care was being provided for service users, some of the care staff spoken to felt that the care was continually improving. The home is trying to involve service users/relatives within care planning; this is being evidenced within the individual care plan. Service users and relatives made the following comments “Service users look clean and tidy”, “I am well cared for and I like living here, staff always knock on the door, they speak nicely to you and I am well looked after medically” and “I haven’t been here long but I am settling well the standard of care is very good”. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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 the following standard(s): 12 13 14 & 15 Activities should be provided which are based on service users likes and dislikes. Relatives are encouraged to visit the home regularly and are made welcome. Menus are varied and comments regarding the food provided within the home were positive. EVIDENCE: Comments regarding the activities being provided were poor and included; “there’s not much to do at all, I would like to get out occasionally” and “there should be more social stimulation for residents”. The activity co-ordinator post is currently vacant. Relatives commented, “I am made welcome and can visit at any time, I am able to have a meal”. Service users spoken with confirmed that they were able to make choices in all aspects of daily living, comments included “I get up and go to bed when I like, staff are very helpful” and “I can make choices in all aspects of my care”. “The food is usually pretty good, the chef will cook something else if I don’t fancy what is on the menu”, “it’s good food” and “I like the cooking here, it’s better than mine”. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 11 The chef confirmed that residents could choose what they wanted and that menus were based very much around what the residents liked. Fresh soup was made daily and the owner will purchase individual items for service users; for example one of the service users likes Heinz tomato soup, another likes an Indian meal on a Saturday these individual choices are catered for. The home has changed food suppliers and now received fresh meat, fruit and vegetables. Specialist diets can be catered for and the staff had attended training on “Focus on Food” which looks at ways of providing nutritionally balanced meals for the elderly. The staff in charge felt that there had been vast improvements in this area. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 12 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): 16 & 18 The complaints procedure should be updated. Systems are in place to protect people from abuse. EVIDENCE: There have been no complaints to the home since the last inspection. Residents and relatives say that they would feel quite happy raising any concerns with staff or management. The complaints form should be updated as it lists CSCI as being responsible for investigating complaints made to the home. This is the responsibility of the home; the policy should be updated to reflect this. The home has clear polices on adult protection which have been updated following the requirement in the last inspection report and staff have all received training in this. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 13 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 There are plans in place to extend and improve the environment. The home was clean tidy and free from odour during the inspection. EVIDENCE: The owner is trying to gain planning permission to extend and improve the premises. A programme of redecoration has started within the home and comments from residents and relatives were positive about this. Decoration has taken place in hallways and bedrooms and new blinds have been fitted in the lounge and dining areas. There were no odours present during the inspection and the home was clean and tidy. The home needs a designated smoking area for residents; at present smokers use the main lounge. One of the non-smokers commented, “I don’t like the smoke”. A discussion took place with the owner regarding this matter who has agreed to seek advice from the fire officer to see if an alternate room can be used. Residents will also be consulted. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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 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): 28 & 29 The arrangements for the recruitment of staff are poor and potentially place residents at risk. EVIDENCE: Recruitment files were looked at as part of the inspection, of the five files examined four did not contain the required two references. The qualified nurse on duty stated that references had been carried out but that she did not know where they were. All staff files must be audited to ensure that they contain all information detailed within Schedule 2 of the Care Homes Regulations. Criminal Record Bureau checks (CRB) had been carried out on all staff. The home has a commitment to training; mandatory training is in the main up to date with courses booked for those who need it. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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 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): 31 33 35 & 38 The owner and manager provide staff with clear guidance and support and operate an open door policy at all times. Financial systems could be further improved to protect residents. Supervision should be provided for all staff. Records in general were up to date, some of the Health and Safety records being used were poor and should be updated. EVIDENCE: Comments about the manager were positive, staff stated, “I am well supported by the manager”, “The management support within the home is good” and “the manager is instigating changes for the better”. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 16 Systems to protect resident’s monies were looked at; a random check was carried out on some of the resident’s monies, the home must ensure that receipts are in place for all expenditure including hairdressing, chiropody, toiletries and all other expenditure. Resident’s finances should be included within the care plans. Although some staff supervision is taking place the nursing staff should also be supervised. All staff working at the home should receive supervisions at least six times during the year. Health and Safety records were looked at; the external checks are up to date and protect residents and staff. The in house Health and Safety checks did not make any reference to some of the fire doors being propped open and was not signed this needs to be looked at. Water temperature checks should also detail any action taken where the temperature exceeds or falls below 43 degrees. The bed rail assessment is not sufficient and must be based on the MDA guidance. Some of the doors are being propped open to enable residents to move in or out, the home should find an alternative way of keeping doors open such as door guards so that residents are safeguarded in the event of a fire. It is advised that the home seeks advice from the Fire officer on this matter. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 X 2 West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? NO 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 OP12 Regulation 16(2)(m) (n) 13(4) c Requirement Timescale for action 31/03/06 2 OP19OP38 3 OP29 19(1) Activities must be made available to service users based on their individual interests and needs. The home needs to review the 31/03/06 arrangements for smoking taking into account risks to service users and staff and advice should be sought from the Fire Officer. Recruitment files must contain 31/03/06 all of the required information, which is detailed within schedule 2 of The Care Homes Regulations. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP2 Good Practice Recommendations The contract should be amended to reflect the visiting arrangements during mealtimes. DS0000062946.V261055.R01.S.doc Version 5.0 Page 19 West House Care Home 2 3 4 OP16 OP35 OP38 The complaints procedure should be amended to reflect the responsibility of the manager and owner in addressing and investigating any complaints. Service users abilities to manage their own monies should be included within care plans. Receipts need to be maintained for all transactions. Door guards or automatic door closers should be fitted where a service users requires their door to be open. Health and safety checks must be signed and dated by the person doing them. Bed rail assessments must be based on the MDA guidance. West House Care Home DS0000062946.V261055.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Care Home DS0000062946.V261055.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!