Inspection on 16/02/06 for West View

This inspection was carried out on 16th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 View 23/06/06

West View 20/09/05

West View 06/01/05

West View 07/07/04

West View 24/02/04

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

CARE HOMES FOR OLDER PEOPLE West View Underwood Lane Crewe Cheshire CW1 3SA Lead Inspector Paul Ramsden Unannounced Inspection 16th 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 View DS0000006518.V283750.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 View DS0000006518.V283750.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West View Address Underwood Lane Crewe Cheshire CW1 3SA 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) 01270 212080 www.clsgroup.org CLS Care Services Limited Mrs Belinda Jones Care Home 36 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (15), Mental disorder, excluding learning of places disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20), Old age, not falling within any other category (2) West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 36 service users to include:In the Mental Health Unit: * Up to 20 service users in the category of MD(E) (Mental disorder, excluding learning disability or dementia over the age of 65 years) * 1 service user in the category of MD (Mental disorder, excluding learning disability or dementia, under 65 years of age) * 2 service users in the category of OP (Old age, not falling within any other category) In the Dementia Unit: * Up to 15 service users in the category of DE(E) (Dementia over the age of 65 years) * 2 named service users between the ages 58 and 65 years in the category DE (Dementia) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 20th September 2005 2. 3. Date of last inspection Brief Description of the Service: West View is a two-storey care home standing in its own grounds. Access between floors is via two shaft lifts or the stairs. The home is owned by CLS care services, a registered charity and is located on the outskirts of Crewe, close to the local shops and other community facilities. There are adequate car parking facilities available. The home provides care for thirty-six older people, and operates in two separate units - one providing care for residents with dementia and the other for residents who have mental health needs. Residents accommodation consists of 36 single bedrooms. Communal accommodation comprises a main ground-floor lounge, and six separate lounge/dining areas dispersed throughout the building. There are an adequate number of toilets and a variety of bathrooms within the home. There are secure and accessible gardens available for residents. West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 16 February 2006 and lasted for four hours. The home manager was on duty together with the agreed numbers of senior, care and ancillary staff. During the inspection twelve residents, the manager and six of the staff on duty were spoken with. A range of care, health and home records were examined and a tour of the premises, including all lounges and other shared areas was undertaken. Comment cards for residents and relatives/visitors were given to the manager upon arrival. What the service does well: What has improved since the last inspection? A new care planning system is in the process of being implemented. The manager considers that the staff team has continued to develop and work very well together. West View DS0000006518.V283750.R01.S.doc Version 5.1 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 View DS0000006518.V283750.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 View DS0000006518.V283750.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): 1, 3 and 6 Information on the service provided by the home is made available to clients and their relatives/representatives. Residents are assessed prior to admission to ensure that the home will be able to meet their needs. EVIDENCE: The home provides a range of information to residents; these include the statement of purpose, the service user guide and the procedures to be followed in the event of a complaint. A statement within this information says; “Moving to West View is a change of address not a change of lifestyle”. As part of the inspection process the care files of six people living at the home were reviewed. Pre-admission assessments that demonstrated that resident’s individual needs were being assessed in an accurate and consistent way had been carried out. Those seen contained enough information for staff to be able to meet individual needs. Residents, relatives and other healthcare professionals are involved with the pre-admission assessment. Various risk West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 9 assessments were also completed. A note from a relative seen on one of the files stated; “Please thank everyone for making the admission so painless and the first day so enjoyable”. Intermediate care is not provided at West View. West View DS0000006518.V283750.R01.S.doc Version 5.1 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 and 10 All residents have a care plan that shows how their individual needs are being met. The current system is in the process of being updated The health, social and emotional needs of people living at West View are being identified and met EVIDENCE: The care team leaders are responsible for drawing up a resident’s plan of care. The five care plans seen as part of the case tracking process provided staff members with the necessary information for them to look after a person’s needs. The health and well being of residents was being monitored and an appropriate record of development and actions taken was being kept. There was written evidence to confirm that care plans were being reviewed and where necessary re-written on a regular basis. The care plans seen contained evidence of consultation with residents or their families/advocates. A new care planning system is in the process of being implemented. All personal care is carried out in the privacy of a resident’s bedroom or one of the bathrooms. Residents spoken with confirmed that they had been able to West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 11 express their opinions and wishes about their daily routines. Residents are able to have a telephone fitted in their rooms if they want to and their mail is given to them unopened. Staff members were observed interacting with them in an appropriate, dignified and respectful way. CLS has a written policy on the receipt, administration [including selfadministration] safekeeping, handling, recording and disposal of medication within its homes. The home uses a blister pack system dispensed by a local pharmacist. Although no obvious issues were seen during the inspection visit the manager explained that she had recently undertaken a management audit of the medication systems within the home and was in the process of addressing the issues identified. West View DS0000006518.V283750.R01.S.doc Version 5.1 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): 12, 13, 14 and 15 Routines at the home are flexible to suit residents’ individual preferences and they are able to maintain contact with their family and friends. The food provided to residents is of a good quality. EVIDENCE: Residents were able to move around freely within their unit and a choice of sitting areas was available. Residents confirmed that routines within the home were flexible and that they were able to make choices in many areas of daily living, for example times of rising and retiring, where to spend their time and with whom and participation in planned activities. Staff members were observed to knock on the door and to await permission before entering a resident’s bedroom. The residents made a number of positive comments regarding the care and services provided at West View. Visitors are free to visit the home at any reasonable time. The home has an activities co-ordinator for each unit; their role involves working with residents, both individually and in groups. A variety of social and other activities are organised and information about forthcoming events were displayed on the notice board and throughout the home. A computer is available for residents if they wish to use it. Links with the local community are maintained. West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 13 Meals can be eaten in the dining room or in the privacy of residents’ own rooms. There is a menu that has the flexibility to meet individual needs and choices. All of the residents that commented said that the food was good and that choices were available. Special diets are prepared where necessary. West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 14 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): None of the standards were inspected during this visit. The key standards were assessed as having been met during the previous inspection. EVIDENCE: None of the standards were inspected during this visit. The key standards were assessed as having been met during the previous inspection. West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 15 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, 20, 21, 24 and 25 The home, which is purpose-built, provides facilities to meet the needs of older people. Standards of hygiene and cleanliness are good. EVIDENCE: A tour of the premises was undertaken; this included all communal areas and a number of bedrooms. The home both externally and internally is maintained to a good standard. Some of the carpets within the home have recently been replaced. Bedrooms seen during the inspection were personalised, comfortable, well-furnished and contained items of furniture belonging to residents’. The manager explained that some of the beds were due to be replaced in the near future. West View DS0000006518.V283750.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff members were seen to be working positively with residents, families and visiting professionals to improve the quality of life of people living in the home. New staff members undertake an appropriate induction when starting work at the home. EVIDENCE: Staff members were cheerful and friendly and residents were complimentary about their attitude and competence. New staff members are routinely inducted through the company’s induction scheme to ensure that they are suitably trained when starting work. An example for a new staff member was seen during the visit. CLS introduced a new induction policy and procedure in December 2005. West View DS0000006518.V283750.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 and 38 The home is being well run and managed on a day-to-day basis. The service collects feedback regarding the quality of the care provided. Residents’ personal allowances are being handled appropriately. EVIDENCE: The home has an experienced and competent manager who is registered with the Commission for Social Care Inspection. She has completed the registered managers award. A quality assurance survey to ascertain whether residents and families are happy with the standards of care being provided has been undertaken. West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 18 Residents’ personal allowances are being handled appropriately. Personal monies were being kept securely and those inspected had correct balances and accurate records. There is a comprehensive health and safety manual as well as policies and procedures in relation to safe working practices in place. Staff members confirmed that they had access to a variety of training courses. The home manager was carrying out moving and handling training with a number of staff on the day of the inspection. Monthly visits to comply with regulation 26 of the Care Homes Regulations are being carried out West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 19 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 X X 3 3 X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 20 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. Standard Regulation Requirement Timescale for action 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 Standard Good Practice Recommendations West View DS0000006518.V283750.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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. 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