Inspection on 23/06/06 for West View

This inspection was carried out on 23rd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 16/02/06

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 Key Unannounced Inspection 23rd June 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.V291154.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.V291154.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.uk 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.V291154.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 16th February 2006 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 West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 5 number of toilets and a variety of bathrooms within the home. There are secure and accessible gardens available for residents. The current fee range for the home is £417 - £505 per week. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit, part of the service’s key inspection, was carried out on 13 June 2006. All of the key standards for older people were looked at during the visit. The Care Team Leaders for the two units were on duty together with the agreed numbers of care and ancillary staff. Thirty-four people were living in the home at the time of the visit. During the visit eleven residents, three visiting relatives, the home manager, home services manager and six of the staff on duty were spoken with. Due to the need for the manager to attend a previously arranged appointment feedback on the findings of the inspection was given to her on Thursday 29 June 2006. A range of care, health and home records were examined and a tour of the premises, including all lounges, other shared areas and a number of bedrooms, was undertaken. CSCI comment cards for use by residents and relatives/ visitors were given to the manager upon arrival at the home. Prior to the site visit the inspector spent time checking the information that had been provided by the home and the notifications, required under Regulation 37 of the Care Homes Regulations, made to CSCI about significant incidents in the home since the last inspection. What the service does well: Staff members provide a good standard of care to the residents that live at West View. Positive relationships were seen to exist between residents and staff and those people that commented all said that the staff members were good. One of the residents said that “the staff are very good, I like to stay busy”. The visiting relatives spoken with said that both the home and the staff working there were marvellous, I have every confidence in them”. Residents said that routines within the home were flexible and that this gave them some control over their lives and enabled them to be more independent. A statement within the information provided to residents says; “Moving to West View is a change of address not a change of lifestyle”. West View provides a safe and well-maintained environment for residents. Catering within the home appeared to be well managed and all of the residents spoken with said the food was good. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? 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.V291154.R01.S.doc Version 5.1 Page 8 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.V291154.R01.S.doc Version 5.1 Page 9 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 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and opportunities to visit before moving in are available and residents are assessed before moving in to ensure that their needs can be met at the home. 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”. One of the visiting relatives said; “We were going to look at three homes, and visited unannounced, the staff member we saw invited us in and we decided there and then”. As part of the inspection process the care files of four people living at the home were looked at. Pre-admission assessments demonstrating that a resident’s individual needs were being assessed in an accurate and consistent West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 10 way had been carried out. Senior staff from the home carried out the assessments. Copies of information provided by the placing authority were also seen on the files. Residents, relatives and other healthcare professionals are involved with the pre-admission assessment. Intermediate care is not provided at West View. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 11 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 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had a plan of care providing details of their needs so that staff members were able to take appropriate action to meet the residents’ health, social and emotional needs. EVIDENCE: The care team leaders are responsible for drawing up a resident’s plan of care. The 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. Whilst there was written evidence to confirm that care plans were being reviewed and where necessary re-written on a regular basis this was not being done consistently on a monthly basis. See recommendation No 1. The care plans seen contained evidence of consultation with residents or their families/advocates. A new care planning system has recently been implemented. Where possible an individuals care plan is kept in their own room. One of the visiting family members confirmed that she had been West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 12 involved in the drawing up and review of her relatives care plan and was kept fully informed about their care. The staff members at the care home continually the residents’ health needs and there was evidence to show that residents were receiving appropriate support from health care professionals. This included GPs, community nurses, optician, dentist and chiropodist. During the visit the staff members were able to demonstrate that they had the ability to deal with an emergency situation. Regulation 37 notifications received also demonstrated that they had dealt with previous issues in an appropriate manner. 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 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. It was seen throughout the visit that residents were being treated with courtesy, respect and good humour by staff. Staff members were seen to be interacting with individuals in an appropriate and respectful manner, knocking on bedroom doors before entering and addressing people appropriately. 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 is currently monitoring the medication systems within the home as part of her auditing responsibilities. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were positive about the home and the support they received so they could maintain contact with friends and family and make choices about their daily lives. EVIDENCE: Residents were able to move around freely within their unit and a choice of sitting areas was available. They 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, participation in planned activities and where to spend time and with whom. Staff members were seen to knock on doors and to await permission before entering residents’ bedrooms. The residents and visiting relatives spoken with made a number of wholly positive comments during the visit. Three of the residents spoken with in a lounge all said that the staff members were good and that they enjoyed living at West View. 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 West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 14 available for residents if they wish to use it. Links with the local community are maintained. 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. One of the visiting relatives said that he was always made to feel welcome and is offered something to eat on a regular basis. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 15 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 and 18 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to voice their opinions and said they would be listened to and action taken to respond to their concerns. Adult protection training for staff is available to ensure the continued safety of residents. EVIDENCE: There is a written complaints procedure for the home. This is also included in the Statement of Purpose and Service User Guide. Those residents and family members that commented said that they would inform the home manager or another senior employee of any concerns or complaints. The pre-inspection questionnaire states that no complaints have been received by the home since the previous inspection. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance ‘No Secrets’. Staff members have received training in this area. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 16 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, 23, 24, 25 and 26 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation is well maintained, with suitable facilities so that residents live in a safe, clean and comfortable home. EVIDENCE: A tour of the premises was undertaken; this included communal areas and a number of bedrooms. Although the home is generally being maintained both externally and internally to a good standard the entrance area and corridors would be improved if they were redecorated. See recommendation No 2. Furnishings, fittings and lighting of the communal rooms are domestic in character. Bedrooms seen during the inspection were personalised, comfortable, well-furnished and contained items of furniture belonging to residents’. West View has two passenger lifts available to allow access between floors. The home also provides adaptations for use by residents with mobility West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 17 problems. These include bath and toilet aids, hoists, grab rails and wheelchairs. The home was found to be clean and tidy on the day of inspection. The laundry is appropriately equipped and good systems are in place for the care of peoples’ clothes. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 18 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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members work positively with residents, families and visiting professionals to improve the quality of life of people living in the home and new staff members are subject to thorough checks so that residents are protected from possible harm. EVIDENCE: Staff on duty and rotas seen demonstrated that staffing levels and the skill mix of staff is adequate to meet the needs of the residents within the home. Staff members were cheerful and friendly. Residents were complimentary about staff attitude and competence. The pre-inspection questionnaire shows that 33 of staff members are currently qualified to NVQ level 2 in care, a recognised qualification for staff involved in delivering care. A number of other staff members are currently undertaking this qualification. The files for two recently appointed members of staff seen contained all of the required information and a robust recruitment procedure was in place for the protection of residents. Prospective staff members are checked against the POVA list before employment commences and CRB disclosures are obtained. New staff members undertake an induction-training programme. Copies of induction records were seen on the day of the visit. Staff members also confirmed that this had happened and that they had worked as a West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 19 supernumerary staff member when they had commenced employment. There are various in-house training programmes available for staff members. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 20 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, 36 and 38 The quality rating for this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to make sure that residents are safe. EVIDENCE: The home has an experienced and competent manager who is registered with the Commission for Social Care Inspection. She has attended courses/training in order to fulfil her management responsibilities and has demonstrated an awareness of the needs of the client user group and how to manage the staff group. She has completed the registered managers award. A home services manager and senior staff members support the manager. The residents and family members that commented said that the home’s management team were approachable and supportive. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 21 Attempts are being made to seek the opinions of residents about the quality of service provided by the home; comments cards and a feedback box are located in the entrance area. A quality assurance survey to ascertain whether residents and families are happy with the standards of care being provided has been undertaken. Copies of the results are available. This is an on-going process and a new survey is to be undertaken in the near future. Residents’ personal allowances were inspected; those checked had correct balances and were being well managed. The systems for the recording of any monies or valuables held were good. All staff members are supervised on a continuous basis. There was evidence that staff were receiving training in areas such as dementia, moving and handling and first aid. The home manager maintains a training record for all staff members employed at the home. The maintenance records demonstrated that the appropriate service contracts were in place. These included the passenger lifts, hoists and fire alarm system. The fire safety record was seen during the visit. This showed that the fire alarm and emergency lighting systems were being tested at the intervals recommended by Cheshire Fire Service. From the records available it was not possible to ascertain whether all staff members had received twice yearly training in fire safety at the recommended intervals. See requirement 1. Monthly visits to comply with regulation 26 of the Care Homes Regulations are being carried out. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 22 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 2 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 3 17 X 18 3 2 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 23 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. 1 Standard OP38 Regulation 23 [4] Requirement Staff training in fire safety must be undertaken at the intervals recommended by Cheshire Fire Service. Timescale for action 30/08/06 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 Refer to Standard OP7 OP19 Good Practice Recommendations All care plans should be reviewed on a monthly basis. The entrance area and corridors should be redecorated. West View DS0000006518.V291154.R01.S.doc Version 5.1 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI West View DS0000006518.V291154.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. 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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