Inspection on 15/08/07 for Westbourne

This inspection was carried out on 15th August 2007.

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

Westbourne 17/01/07

Westbourne 22/05/06

Westbourne 21/09/05

Westbourne 09/05/05

Westbourne 02/11/04

Westbourne 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westbourne 9 Bedford Road Hitchin Hertfordshire SG5 2TP Lead Inspector Jeffrey Orange Unannounced Inspection 15th August 2007 10:00 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 Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbourne Address 9 Bedford Road Hitchin Hertfordshire SG5 2TP 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) 01462 459954 01462 459954 b.bains1@ntlworld.com Mr Balbir Bains Mrs Kulvinder Bains Angela Valerie Bowes Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only bedrooms 4 and 15, which measure 17.5 square metres, can each be shared by 2 persons through positive choice and mutual agreement. 17th January 2007 Date of last inspection Brief Description of the Service: Westbourne is a large detached two-storey house, situated close to the centre of Hitchin, which has been converted for use as a care home for elderly people. The original house was built in 1859 and has been extended. It has a total of twenty-five bedrooms, two of which can be shared by two people through positive choice and mutual consent. The ground floor has an entrance lobby, two lounges to the front, one lounge, one dining room and a conservatory to the rear, the main kitchen, an office and eight bedrooms, all of which have ensuite wash hand basins and toilet and two of which also have showers. There is also one assisted bath. The laundry is situated in the basement. A passenger lift serves the first floor. The first floor has seventeen bedrooms, five with wash hand basins only, nine with en-suite wash hand basin and toilet and three with showers in addition. There is a hip- bath and two assisted baths. There are gardens to the front and rear of the home with parking available at the front of the home. The home has a statement of purpose and service user guide to provide information to prospective service users and copies of the latest inspection report from the Commission for Social Care Inspection (CSCI) are also available in the home. Current charges range from £380 - £565 per week. Additional charges apply for chiropody, dentistry and opticians’ services and for newspapers, hairdressing and personal toiletries. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one weekday morning and early afternoon and provided an opportunity to talk to people who live in the home and the staff who care for them as well as to observe the care provided during the daily routine of the home. Key records were examined, including care plans, staff recruitment files and medication records. Discussions were also held with the manager and her deputy. This inspection report is also informed by any information received by the Commission for Social Care Inspection (CSCI) about Westbourne since the previous inspection in January 2007. The ongoing inspection process will include surveys of some of the people living in the home and their relatives, together with healthcare professionals associated with the home. The home will also be making an annual quality assurance return to the CSCI. What the service does well: What has improved since the last inspection? The activities programme has continued to be developed and improved and now provides those people who choose to participate with a range of craft, musical and social activities throughout the day. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 6 Requirements and recommendations made following the previous inspection have been addressed. There have been some further improvements made to the environment of the home including redecoration and refurbishment of some bedrooms and communal areas. “It is an entirely different home” was the very positive assessment of a longstanding resident and that comment reflects the finding of this inspection visit. The manager and her staff team together with the proprietors have maintained those improvements noted in the previous report and have taken them forward. Whilst all staff, the management team and the proprietors can take some pride in what has been achieved at Westbourne during the past 18 months, the most important thing is that these improvements have benefited the people who live in the home and who depend on the staff to provide them with a safe and comfortable home and with the high standard of care that they deserve. 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. The summary of this inspection report can be made available in other formats on request. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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 Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 3 (Standard 6 does not apply to Westbourne) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information about charges that is provided for people considering Westbourne as a home for themselves, or someone they are responsible for provides sufficient detailed information to avoid confusion as to the fees that apply and what they cover. There is a thorough and robust assessment process that should ensure that only those people whose care needs can be appropriately met are admitted to the home. EVIDENCE: The Service User’s Guide, which is available on an audiocassette for those who find reading difficult, has recently been reviewed and revised to make charges and details of what is included clearer and more transparent. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 9 A series of care plans for people who have recently been admitted into the home were seen to include comprehensive pre-admission assessments, which identified their care needs and, taking into account their preferences and right to choose, how these would be met. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of care planning is good, the needs of people living in the home are clearly identified and care plans include the information needed by staff so that they can meet those needs and review any changes in them. The home has an efficient medication policy in place, which staff understand and follow. Medication records are accurate and there is a robust system of management checks in place to monitor compliance. This provides people living in the home with confidence that their medication will be stored, administered and recorded safely and accurately. The healthcare needs of people living in the home are met by care staff and by the appropriate involvement of community healthcare professionals and services. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 11 EVIDENCE: Medication storage and records of administration were checked and found to be in good order, with accurate entries and a high level of hygiene in the storage of medication and neat and clearly legible entries on administration records. Evidence was seen of a robust management monitoring process in place. On those occasions when any non-compliance was found there was evidence that appropriate action was taken. The standard of care observed was good, with people living in the home treated with dignity and respect throughout. “The staff are much happier and provide us with very good care” was one comment made during this inspection visit. A sample of care plans was seen and these were well completed, with a good level of meaningful and relevant information included. A delivery of community aids was made to the home during this inspection visit. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are able to maintain and develop family and community contacts. There is a range of social activities that take place throughout the day and efforts are made to tailor these activities to the individual interests of people living in the home. The standard and choice of food in the home is good and takes account of the expressed preferences of people living in the home. The home has a formal process of meetings and surveys in order to enable people living in the home and those responsible for them to influence and discuss daily life in the home. EVIDENCE: A discussion was help with one of the two activity organisers who discussed how she tries to ensure that people’s needs and interests are met through the regular programme of activities available as well as by “one offs” like a recent trip to a private garden. The home is a member of a national body that provides advice and guidance on the provision of activities for older people. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 13 Service users were very complimentary about the food provided and the mealtime observed at the close of the inspection was a pleasant, sociable event, with those people who required assistance receiving it in an appropriate and respectful manner. A recent report by the Local Authority Environmental Health body had made three requirements all of which had been met, including provision of a more efficient refrigerator, replacing a small area of tiles and making provision for Food & Hygiene training for a member of the catering staff whose first language is not English. Reports and minutes of relative and meetings for people who live in the home were seen and further meetings are scheduled. There were effective displays of recent activities that have taken place in the home in the reception area of the home. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 17 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints policy and procedure in place and staff receive appropriate training to support this and put it into practice. This should ensure that any complaints received are dealt with promptly and appropriately. People living in the home and those responsible for them can feel confident that they are being protected from potential abuse. EVIDENCE: People living in the home have consistently said when spoken to or surveyed by the CSCI that they know how to make a complaint and that they are confident that it would be acted upon. Training for staff includes how to recognise abuse, in all its forms, and what to do if it is seen or suspected. No complaints about Westbourne have been received by the CSCI since the previous inspection in January 2007. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people who live and work there with a safe, clean and comfortable environment and includes the necessary facilities and equipment they need to help them meet their daily living needs. EVIDENCE: The building was free from any unpleasant smells throughout this visit, which started quite early in the day. Communal areas are well presented and comfortable and are available in different locations throughout the home and of different sizes. A programme of redecoration of bedrooms has continued and two of the newly decorated rooms were seen. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 16 There is a maintenance and development programme in place for the building, to include improved office accommodation for the manager as well as further improvement to the accommodation of people living in the home. This combination of an improvement both in the standard of care experienced by people living in the home and the environment in which they receive that care is one of the factors behind the notable improvement in the home’s rating that has occurred over recent inspections. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home and rely on some degree or other of help with their personal care can be confident that that care is being provided by sufficient numbers of staff with the skills and experience needed to do so safely and appropriately. The home’s recruitment practice is sufficiently robust and thorough to give people living in the home confidence that unsuitable people will not be employed to provide them with care and support. Previous concerns about the language skills of some staff have been allayed and no adverse comments were received during this visit. The position will continue to be monitored through the ongoing inspection process. EVIDENCE: Training records were seen to include the necessary routine training for care staff and some members of the staff team were spoken to about the training they receive and were able to confirm details of, for example moving and handling and Protection of Vulnerable Adults training that had been undertaken. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 18 No issues about staff numbers or problems with communication were raised with the inspector by people living in the home during this inspection visit “The staff are happier” was the observation of one person living in the home and the relaxed and calm atmosphere throughout this visit bore that view out. Recruitment files were seen for recently employed staff and they were found to include the necessary information and checks undertaken to ensure that people living in the home are adequately protected from the employment of unsuitable people in the home. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 32 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a very well managed home that benefits from a strong lead from the registered manager and her deputies, supported by a well motivated and supported staff team as well as by the proprietors. The manager ensures that staff follow the policies and procedures of the home and that they are given the training, supervision and support they need to do so effectively and efficiently. The views of people who live and work in the home are listened to and valued and there is a structured system of quality assurance in place. The home has efficient systems in place to ensure effective safeguarding and management of individual’s money. There is a robust and through system of risk assessment in place which is kept under regular review and should provide for the safe care and wellbeing of Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 20 people who live and work in the home. EVIDENCE: Detailed conversations were held with the manager and one of her deputies. This provided clear evidence of a management team that was open and accessible, well qualified and keen to undertake additional personal development training, including at advanced NVQ level. People living in the home and members of the staff team spoken to throughout this inspection visit were very positive about the changes in the management team and the positive and beneficial effect this had had on the day to day experience of living and working in the home. Financial records for people living in the home were spot checked and found to be in order. Equipment throughout the home is routinely and regularly serviced and insurance cover is in place to protect the best interests of staff and people living in the home. The record of regular meetings held with people living in the home and some of their relatives were seen. Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 21 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 3 17 3 18 3 3 X X X X X 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 4 3 X 3 X X 3 Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 22 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 Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Westbourne DS0000019611.V347005.R02.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!