Inspection on 02/02/06 for West House Residential Home

This inspection was carried out on 2nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Residential Home 25/11/08

West House Residential Home 26/11/07

West House Residential Home 09/10/06

West House Residential Home 28/09/05

West House Residential Home 06/12/04

West House Residential Home 06/09/04

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

CARE HOMES FOR OLDER PEOPLE West House Residential Home 14-16 Quarry Road Westtown Dewsbury West Yorkshire WF13 2RZ Lead Inspector Tracey South Unannounced Inspection 2nd February 2006 09:30 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 Residential Home DS0000045064.V254514.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 Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West House Residential Home Address 14-16 Quarry Road Westtown Dewsbury West Yorkshire WF13 2RZ 01924 469416 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) Northfields Care Homes Ltd Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: West House is a home for thirty-eight older people with dementia care needs. The home is owned and managed by Northfields Care Homes Ltd based at Dewsbury. The home is situated approximately one mile from Dewsbury town centre close to the main Huddersfield Road, and consists of a large Victorian house that has been extended twice in recent years. There are pleasant gardens to the front of the house. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over approximately 5 hours. Health and safety documentation, medical records, staff records and residents’ financial records were examined during this inspection. A brief tour of the home was carried out which included a small number of residents’ bedrooms. Since the last inspection the registered manager has left the home and the acting manager is Mr Rod Turner. Mr Turner was present throughout the inspection. There were 35 residents living at the home. Five residents, the acting manager, and four members of staff were spoken to and their comments have been included within this report. What the service does well: What has improved since the last inspection? The statement of purpose has been updated and includes the relevant information people need to know when choosing a home for their relatives. As recommended in the last report, all medication received in the home is now being booked in. Medication records were found to be neat and tidy. Details of residents’ wishes during illness and following death, when known, are being recorded within the resident’s care plan. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 6 Progress is being made in relation to staff writing meaningful daily reports. Further work on this is still required. 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 Residential Home DS0000045064.V254514.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 Residential Home DS0000045064.V254514.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): EVIDENCE: None of the above standards were assessed on this occasion. West House Residential Home DS0000045064.V254514.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): 10 Residents are treated with respect and the right to privacy is upheld. EVIDENCE: Staff were observed assisting residents in a sensitive and caring manner. Staff explained how they offer discreet support to those residents who have difficulty with feeding themselves. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 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 Progress is being made to ensure that residents receive stimulating activities. Relatives are able to visit at any reasonable time. Residents receive a well balanced diet. EVIDENCE: The acting manager acknowledges that further progress is required to ensure residents receive stimulating activities on a more structured basis. Recent comments received from relatives indicated the not enough activities take place. The staff at West House have taken these comments on board and plans are being made to introduce new activities and outings are being arranged. Current activities that do take place include fortnightly armchair exercises, sing-a-longs, skittles and baking. Outside entertainers also visit the home and forthcoming attractions are displayed in the home. A church service was held at the home during January 2006. The visitor’s book is a good indication that the home receives a number of visitors at various times of the day. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 11 The acting manager explained that none of the residents currently living at the home have the capacity to manage their own financial affairs. Small amounts of monies are held on behalf of some residents. Residents are able to bring their own personal possessions with them when they move into the home. Evidence of this was seen whilst undertaking a tour of the home. Staff explained how residents are offered choices at mealtimes. Staff provide residents with menu options on a daily basis. Residents are able to choose from 2 options available at lunchtime. A light meal is served at teatime, which consists of at least 4 or 5 different options. The meal on offer during the day of the inspection was either pork steak or corned beef pie with vegetables and potatoes. The dessert on offer was sponge and custard, alternatives were also available. There are residents who require a soft diet as recommended by the speech and language therapist, the catering staff ensure such diets are provided for. The majority of residents take their meals in the dining rooms available on both floors. Some residents prefer to eat their meals in their easy chair with an over-bed table in place. Staff provide support to those residents who have difficulty with feeding. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 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): EVIDENCE: None of the above standards were assessed on this occasion. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 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 areas within the home in need of redecoration. The home is kept clean and hygienic. EVIDENCE: The lounge on the ground floor is in need of redecoration. A leak on the roof has caused some damage to the decor. The paintwork on a number of doors and skirting boards, on both floors, require repainting. The acting manager explained how bedrooms are redecorated and new carpets are fitted as and when required. The acting manager was not aware of when the environmental health officer last visited the home. He was requested to look into this and inform the CSCI if there are any outstanding recommendations. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 14 The home is kept clean and tidy. There were no unpleasant odours noted during the inspection. Staff were seen responding quickly to spillages. The laundry facilities are sited in the cellar. The home employs 2 laundry staff who cover 7 days a week. The laundry staff at West House take pride in their job and great care is taken with residents’ clothes. The acting manager was advised to implement a risk assessment in respect of the laundry staff, as they are required to climb at least 12 steps from the cellar, whilst carrying laundry baskets. The door to the cellar opens inwards, causing further difficulty for staff. The laundry staff would also benefit from having additional working space in the cellar, for use when folding clean items of linen and clothing. The procedure for the control of infection including safe handling and disposal of clinical waste should be displayed in a prominent place to remind staff of the procedure they should follow. Hand washing facilities are available in the cellar although the sink appears to leak. Liquid soap and paper towels must be made available. West House Residential Home DS0000045064.V254514.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): 29, 30 Residents are protected by the home’s recruitment procedures. EVIDENCE: The file of a newly recruited member of staff was examined. There was evidence in place to confirm that the home carried out the necessary employment checks prior to the person starting work. It was noted that CRB disclosures are being copied and kept on file. In accordance with data protection guidance, CRB disclosures should not be copied and should be destroyed upon receipt. The CSCI request that CRB disclosures are kept for at least 6 months or until the next inspection. The manager was advised that he could now destroy all current disclosures. It would be helpful if the reference request currently being used is amended to include the referee’s signature and the date they complete it. There was no information available on the day of the inspection in order to demonstrate that staff have received any training since the last inspection. This is particularly disappointing in respect of adult protection training as a requirement was made in the last inspection report to ensure that all staff received such training by the end of December 2005. The CSCI are only aware of 5 staff who attended adult protection training on 6.12.05. This must be addressed as a matter of urgency. However, information was provided after West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 16 the inspection indicating that a number of training courses have taken place over the past 5 months. The registered owner provided details that 19 candidates have achieved 57 certificates, in 19 different training courses. Staff training records must be readily available in order to demonstrate that staff have received training in order for them to carry out their jobs. The CSCI must be informed of all training taken place since the last inspection. West House Residential Home DS0000045064.V254514.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): 31, 33, 35, 38 The home is run in the best interests of residents. Resident’s financial affairs are safeguarded. Health and safety certification is not readily available. EVIDENCE: The acting manager is Mr Rod Turner. Mr Turner has returned to West House after previously managing the home approximately 2 years ago. In order to register Mr Turner with the CSCI a completed application form must be sent to the Brighouse office. Mr Turner explained how he welcomes suggestions and comments from staff about how the home is managed. He encourages staff to participate in day to day decisions affecting the residents. Staff made positive comments about the manager and all felt he was approachable and supportive. Written comments West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 18 received from relatives were complimentary about Mr Turner and were pleased to hear of his return to West House. Mr Turner is a Registered Mental Nurse with a number of year’s experience of working with people with dementia and mental health needs. The management staff within Northfield Care Homes Ltd actively seeks the views and opinions of relatives to ensure the home is run in the best interests of the residents. The acting manager recently sent out comment cards to relatives requesting them to make any comments about the home. The comment cards received gave positive feedback about the care provided at West House. Some relatives felt that there were not enough stimulating activities taking place, and as previously mentioned, the staff at the home, are currently arranging activities and outings to rectify this. In addition to this two members of staff have been allocated the role of activities co-ordinators. The co-ordinators will take on the responsibility of arranging activities as well as finding out from the residents the type of activities they would like to do. The Quality Assurance Manager, Mrs Schofield, carries out monthly visits to the home. During the visit Mrs Schofield seeks the views of staff, residents and any visitors to the home. Their comments are recorded within the quality assurance report. The information gathered during the visit is then discussed with the owner of Northfield Care Homes Ltd and the manager as part of the company’s management meetings. Small amounts of monies are kept on behalf of residents. Four resident’s monies were checked all of which were found to be correct. The manager needs to create a system for the safe keeping of health and safety certification as a number of documents could not be located on the day of the inspection. Regular fire alarm checks and fire drills are taking place although there was no evidence to suggest that staff had received any fire training since January 2005. This needs to be addressed. Water temperatures are taken and recorded on a monthly basis only no checks had been carried out in the month of January 2006. There was no evidence in place to suggest that slings used in association with hoists have been serviced along with the lifting equipment. The acting manager must address this. It was noted that the passenger lift had been serviced in January 2006 when a number of items were listed as not working, mainly the emergency bell and lighting. Mr Turner was unaware of this until the day of the inspection. Since the inspection the CSCI has been informed that the necessary parts have been West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 19 ordered and are due to be fitted week beginning 13th February 2006. In the meantime residents and staff have been requested not to use the passenger lift unless it is absolutely necessary. Risk assessments have been implemented outlining the identified risk and the measures in place to reduce the risk. Accidents are reported and recorded although records maintained are kept collectively. In accordance with the Data Protection Act all information recorded in the appropriate accident book, must be filed in the resident’s own file. One of the sluice rooms on the ground floor had been left open. The lock was broken. There was a second lock on the door requiring a splined key to operate it. The acting manager was unaware whether the splined key was being used to lock the door. This needs to be addressed. In the absence of detailed records a requirement has been made in this report for the acting manager to provide the Commission for Social Care Inspection with further information relating to health and safety issues. The manager was advised to review COSHH assessments at least every 12 months to ensure they are still relevant. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 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 x x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 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 x 17 x 18 x 2 x x x x x x 1 STAFFING Standard No Score 27 x 28 x 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 x 3 x x 1 West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 21 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. 4. Standard OP18 Regulation 13 Requirement All staff must receive Adult Protection training within the next three months. Brought forward from the last inspection report 28.9.05. Timescale not met in full. The procedure for the handling and disposal of clinical waste must be made available to staff and ideally sited in both the laundry and sluice rooms. Liquid soap and paper towels must be made available to the laundry staff. The leaking sink must be repaired. A risk assessment must be implemented in respect of the activities undertaken by the laundry staff. In order for Mr Turner to undergo the fit person process an application must be submitted to the CSCI. The manager is expected to achieve the Registered Manager’s Award or equivalent. All staff must receive training in order for them to carry out their DS0000045064.V254514.R01.S.doc Timescale for action 31/03/06 1 OP26 13(3) 28/02/06 2 OP26 13(3) 28/02/06 3 OP38OP26 13(4) 28/02/06 4 OP31 9 28/02/06 5 6 OP31 OP30 9 18 30/09/07 28/02/06 West House Residential Home Version 5.1 Page 22 7 OP38 13 8 9 OP38 OP38 23 13 10 OP38 13 jobs. Training records must be readily available for the purpose of inspection. Records relating to health and safety certification must be readily available for the purpose of inspection. All staff must receive fire lectures at least twice yearly. All sluice doors must be kept locked. The broken lock identified must be repaired or replaced. Slings must be serviced along with lifting equipment. Confirmation that the passenger lift is in good working order must be sent to the CSCI. Timescale 14/02/06 Accident records must be kept in the resident’s own file in accordance with the Data Protection Act. Timescale: 28/02/06 28/02/06 30/03/06 28/02/06 30/03/06 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 4 5 Refer to Standard OP12 OP19 OP19 OP26 OP38 Good Practice Recommendations Residents should receive stimulating activities in accordance with their likes and preferences. The manager should inform the CSCI if there are any outstanding recommendations for the environmental officer’s last visit to the home. Doors and skirting boards are in need of repainting. The laundry staff would benefit from additional working space used when folding clean linen. The water temperatures should be checked monthly. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 23 COSHH assessments should be reviewed every 12 months. The following information is requested 1. Has the water undergone testing for Legionella? If so, when? 2. When were the boilers and central heating system last serviced? 3. How many staff are qualified first aiders? Please send the above information by 28th February 2005. West House Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Residential Home DS0000045064.V254514.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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