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Inspection on 28/09/05 for West House Residential Home

Also see our care home review for West House Residential Home for more information

This inspection was carried out on 28th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The residents at the home were only able to give limited feedback about their life at the home. However, the feedback received indicated that residents are happy at West House. Residents and staff were seen to interact well with each other. Staff were seen to be patient and understanding of the needs of the residents. A recent outing on a barge had taken place and the feedback received was that it was a good day, enjoyed by all those who were able to go. The home receives a number of visitors and feedback received in previous inspections is that they are made to feel welcome. There are enough staff on duty to make sure residents are cared for properly. Over 50% of the staff have now achieved their NVQ level 2 in care.

What has improved since the last inspection?

The manager has a much better understanding of the need to protect people when recruiting new staff, by ensuring the appropriate employment checks are undertaken.

What the care home could do better:

Daily reports need to written in such a way that captures how the resident has spent their day and that their care needs have been met. All medication given to residents must be signed for at the time it is administered. Details of residents` wishes during illness and following death need to be written down, so that staff know how to look after them when the time comes. Staff need to attend training about adult protection, to make sure residents are never placed at risk.

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 28th September 2005 09.20 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.V254074.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 Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 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 Jennifer Stanley Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the work required by the West Yorkshire Fire Safety Officer under Schedules 1 and 2 is completed by 31 August 2003. 6th December 2004 Date of last inspection 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.V254074.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over approximately 6 hours. Care documentation and duty rotas were inspected. A brief tour of the home was carried out although this did not include residents’ bedrooms. There were 36 residents living at the home on the day of the inspection. Five residents, the manager and 5 members of staff were spoken to. There has been one additional inspection visit since the last scheduled visit on 6th December 2004. What the service does well: What has improved since the last inspection? The manager has a much better understanding of the need to protect people when recruiting new staff, by ensuring the appropriate employment checks are undertaken. West House Residential Home DS0000045064.V254074.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 Residential Home DS0000045064.V254074.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 Residential Home DS0000045064.V254074.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): 1, 3, 4. The current statement of purpose does not provide prospective residents and their relatives up to date information about the home. Pre-admission assessments are carried out by staff who are trained to do so. EVIDENCE: The statement of purpose is currently being amended and reviewed to ensure it is up to date. A copy of the final draft must be sent to the CSCI to ensure it meets with the regulations. This must be completed by the end of November 2005 as this requirement has remained outstanding for a considerable amount of time. The manager explained that there have been no new admissions to the home since the last inspection. One pre-admission assessment was examined and was found to be satisfactory. The prospective resident received a visit from the registered owner, who carried out the assessment. Information about the needs of that person were recorded in writing. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 9 The manager has a good understanding of the needs of people with dementia related illnesses. She has undertaken dementia care mapping training, which she found to be beneficial. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 10 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): 7,8,9,11 Care plans are detailed and give staff the information they require to meet residents’ needs. The health care needs of residents are being met with health care professionals being involved as necessary. Staff do not always follow correct procedures when administering medication. EVIDENCE: Care plans set out in detail the action required by staff to ensure the needs of the residents are met. The manager and a member of the senior care team have recently updated a number of care plans. There was evidence that staff are vigilant and new care plans are put into place as the needs of residents change. Care plans are being reviewed on a monthly basis. More care is needed in ensuring that the daily reports reflect how the resident has spent their day and that their needs, in accordance with the care plan, have been met. The health care needs of residents are being met. There was evidence in place that visits by health care professionals take place as necessary. District nurses provide nursing treatment to residents assessed as needing this kind of support. Waterlow assessments are used to identify those residents who are West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 11 at risk of developing pressure sores. Specialist equipment is accessed via the district nursing team. There are a number of assessments in place, for example, nutritional, oral health, movement and handling, continence and individual risk assessments. All assessments are reviewed on a regular basis and amended according to any change in the resident’s needs. Medication records are not being maintained correctly. Staff are not always signing for medication they have administered. There were a number of signature omissions noted on the majority of medical records inspected. All staff must be made aware of the need to sign for medication contemporaneously to avoid mistakes being made. This needs to be addressed as a matter of urgency. Care plans do not contain information about resident’s wishes regarding the care and support they want during illness and following death. This needs to be addressed. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 12 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): None of these standards were assessed on this occasion. EVIDENCE: West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints procedure in place. There are procedures in place to protect residents from abuse or neglect. However, without staff being trained in these procedures residents may be placed at risk. EVIDENCE: The complaints procedure is on display within the home. The manager said there have been no complaints made direct to the home since the last inspection in December 2004. The CSCI received one complaint in respect of the home in June 2005. Details of this can be obtained upon request. Although Northfield Care Homes Ltd has its own adult protection procedures in place the staff have received no formal training. This was identified at the last inspection visit in December 2004. This must be addressed as a matter of urgency and a requirement is made to ensure all staff receive this training within the next 3 months. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 There are enough staff on duty to meet the needs of residents. Staff have worked hard to achieve their NVQ qualification in care. EVIDENCE: The manager or team leader is in charge of each shift. The morning shift consists of 6/7 staff on duty with 6 staff on duty on the afternoon shift. Three members of staff work wakeful nights. The care staff are supported by, domestics, cooks and laundry staff. Two care staff are deployed to work on each of the ground and first floor accommodation, with one member of staff used as a “floater” between the two. There are 26 care staff currently employed as West House, 17 of which have acquired their NVQ level 2 qualification in care. The manager explained that there have been no new staff employed at the home since December 2004, therefore standard 29 was not assessed during this inspection. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 16 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): None of these standards were inspected on this occasion. EVIDENCE: West House Residential Home DS0000045064.V254074.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 1 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 X X X X X X X x STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 18 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 OP1 Regulation 4, 6 Requirement The statement of purpose must reflect the current services and facilities on offer. A copy of the final draft must be sent to the CSCI by the end of November 2005. Staff must ensure that they sign for all medication they administer to residents. Care plans must contain information about resident’s wishes regarding the care and support they want during illness and following death. All files must include this information by the end of November 2005. All staff must receive Adult Protection training within the next three months. Timescale for action 30/11/05 2 3 OP9 OP11 13 12 28/11/05 30/11/05 4 OP18 13 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000045064.V254074.R01.S.doc Version 5.0 Page 19 West House Residential Home 1 2 Standard OP7 OP9 Daily reports should reflect how the resident has spent their day and evidence that their needs have been met. The temperature of the medication fridge has not been recorded since July 2005. These records need to recommence. West House Residential Home DS0000045064.V254074.R01.S.doc Version 5.0 Page 20 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.V254074.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. 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