Inspection on 09/05/05 for Westbourne

This inspection was carried out on 9th May 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.

Other inspections for this house

Westbourne 15/08/07

Westbourne 17/01/07

Westbourne 22/05/06

Westbourne 21/09/05

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 Angela Dalton Unannounced 09.05.05 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 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 I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westbourne Address 9 Bedford Road Hitchin Hertfordshire SG5 2TP 01462 459954 01462 459954 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Balbir Bains Care Home 23 Category(ies) of OP OP Old age - 23 registration, with number of places Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Only bedrooms 4 and 15, which measure 17.5 square metres, can each be shared by 2 persons through positive choice and mutual agreement. Bedrooms 24, 25 and 27 which are accessible via some steps to accommodate mobile residents only. Date of last inspection 02.11.04 Brief Description of the Service: Westbourne is a large detached two-storey house, which has been converted for the use as a care home for elderly people. It is situated on a busy main road through Hitchen. The original house was built in 1859 and had been extended. It has a total of twenty one bedrooms, two of which can be shared by two person through positive choice and mutual consent. Ground floor comprises of 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 six bedrooms, five of which have en-suite wash hand basins and toilet and one assisted bath. The laundry is situated in the basement. A passenger lift serves the first floor. The first floor comprises of fifteen bedrooms, eight have en-suite wash hand basin and toilet. Seven bedrooms have wash hand basin only, a sleep in room, hip bath (not in use) and two baths - one assisted and one with a mechanical bath hoist. There is a garden to the front of the home and a smaller one to the rear. There is limited parking facilities to the side of the home. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by 1 inspector and took 61/2 hours. The home manager has submitted her application to register with the Commission for Social Care Inspection. The home had one service user vacancy on the day of inspection. The proprietors visit the home regularly and were present during the inspection. New carpet was being fitted in two bedrooms. Some requirements have been made regarding record keeping and medications. Others pertain to furnishings in the home and aids and adaptations. What the service does well: What has improved since the last inspection? What they could do better: Although the home has three baths to serve twenty-three service users only two are in use. The assisted bath appeared temperamental and lowered when tested despite being in the locked position. The bath is sited at a low level and was reported to cause discomfort to staff whilst they are assisting service users. Due to the design of the assisted bath service users with limited mobility find it difficult to use, as they have to be able to weight bear to get into the seat. The designe of the chair does not secure service users and may feel unsafe. Some service users refuse to have a bath. The size of the bathroom prevents the use of a hoist. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 6 Medication recording and storage need improvement. Radiators remain uncovered and a previously made requirements in two reports remain unmet. The temperature in the conservatory was extremely high and uncomfortable. Service users who could not make their needs known or move independently were sitting in direct sunlight. They were at risk of dehydration and could not sheild sunlight from their eyes. 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. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 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 standard(s) 1,3,4,5,6 Service users needs are identified prior to moving into the home to ensure that they can be met. EVIDENCE: Service users receive information about the home on arrival or prior to moving into the home. Assessments are conducted by the manager using the care plan to ensure that the home is able to meet their needs. There is no separate assessment in place to identify an improvement or deterioration in health. Service users who have been hospitalised are assessed prior to returning to the home to ensure that nursing care is not required and that the home can meet their needs. The home does not offer intermediate care but does provide respite. Some service users return to live at the home permanently after a respite stay and it assists with the transition. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Care plans do not provide comprehensive information regarding how service users needs will be met and care delivered. Medication is not accurately recorded. EVIDENCE: Although care plans identify some needs, further guidance and explanation is needed. This would direct staff to appropriately meet service users needs. This is true of all required areas e.g. falls, pressure care, nutritional monitoring and risk assessments. Care plans that the Inspector examined did not reflect individuals’ wishes regarding funeral plans. Individual wishes may not be carried out if not recorded. Care plans require more information to assist staff to meet the specific needs of service users. Falls, presure care and nutrition were areas that lacked information. The home liaises with district nurse who meet service users’ nursing needs where necessary. Medication did amounts did not reconcile i.e. amounts given did not match the amount recorded or the remaining number of tablets; gaps were on Medication Administration Sheets (MAR). A large amount of medication is kept in a small trolley and lids have been ripped off boxes to accommodate medication and removed from its labelled box in one case. This practise is unsafe as medication is unlabelled and is therefore not identifiable. Storage temperatures Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 10 are not recorded to ensure that medication is stored safely. Poor recording of medication exposes service users to the risk of not being given medication or being given the wrong medication. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15 Service users have access to activities and are able to express choice. EVIDENCE: Staff are responsible for ensuring that activities take place, as the home does not employ an activities co-ordinator. The cook also organises activities which service users participate in. The home has links with the local college who run craft sessions. The likes and dislikes of service users activity choices or activities participated in is not recorded. Service users spoke highly of the food. The container used to collect waste food is kept in the dining room while service users are eating. This is rather unpleasant. The daily menu was on display and choices were available. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Service users are aware of the complaints procedure. Their legal rights are protected and they are proctected from abuse. EVIDENCE: Service users stated that if they were unhappy with any issues within the home they would talk to staff or the manager. The home manager is investigating accessing Hertfordshire County Council Adult Care Service’s training for the staff team to accompany the Adult Protection policy. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The environment does not reflect its maximum potential. The safety of service users is compromised. EVIDENCE: Service users who are independent occupy the bedrooms nearest the stairs and should their needs change are moved to a room more suited to their needs. The conservatory was very warm and the temperature measured fortyfour degrees. The baths that are in place are not suitable for all service users and an appropriate alternative must be identified. Furnishings in some of the rooms are a little weary and they are unlikely to be fire retardant due to their apparent age. Beds had solit bases. Armchairs had holes in. The varnish and veneer was missing from some furniture. One of the lights was not working in the rear stairwell which would make it difficult to move about safely at night as it would be dark. Bathroom bins are open and infection control is compromised. Clinical waste practises within the home need to be reviewed as Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 14 staff have to transport incontinence materials to one area in the home. More clinical wast bins would reduce this practise. Radiators remain uncovered and pose a risk to service users who may fall against them and be scalded. The home was clean and odour free. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Documentation did not reflect appropriate recruitment checks had taken place. EVIDENCE: A number of new staff were recruited by the proprietors who used an agency. Not all the required paperwork was in place – references and application forms were not available. The well being and protection of service users is not assured. Training is being sourced for a variety of topics including NVQ. Moving and handling training and dementia have taken place. One of the proprietors stated that they had assisted with personal care, a Criminal Record Bureau check must be completed is required to ensure service user safety. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,37,38. The health and safety of service users is not assured. EVIDENCE: An application has been received to register the manager with the Commission of Social Care Inspection. Staff confirmed that the manager was available and approachable to share any concerns that they may have. A number of radiators remain uncovered posing a risk to service users. A light switch has a notice on saying do not use but no-one spoken to knows why. The high temperature in the conservatory poses a risk to service users who are unable to move independently or make their needs known. Kitchen doors were wedged open and a safe alternative must be employed. Instruction on fire instructions on display had faded and were therfore unable to guide service users, visitors or staff in the event of a fire. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 2 3 2 1 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 x x x x 2 2 Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 18 Yes 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 OP7 Regulation 12(1)(a) & (b) 15(2) & (b) Requirement Comprehensive care plans are required. Management plans relating to falls, pressure care, nutrition and risk assessment must be in place. This list is not exclusive and any other identified needs require a care plan. Medication amounts must reconcile. Administration of medication must be recorded. Where medication is not given or refused then the appropriate code must be used and the reason recorded on the MAR sheet. Details of controlled drugs must be documented regarding address of origin and return of drugs. Storage temperatures must be recorded and monitored. A homely remedies policy must be devised for those service users who are on non prescribed medication. A risk assessment must be in place for service users who self administer medication. Medication must be stored in its original packaging with the pharmacy label in place and not removed. A requirement regarding Timescale for action 31/08/05 2. OP9 13(2) 13/06/05 Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 19 3. OP21 12(1)(a) 13(4)(b) 23(2)(j) & (n) 16(2)(c 23(2)(c) 4. OP24 5. 6. OP25 OP25 23(2)(p) 13(4)(a) & (c) 7. OP29 17 (2) 19 (1) Schedule 2&4 13(4)(c) 8. OP38 9. OP38 23(4)(c) (iii) recording medication was made at the previous inspection. Baths must be suitable for service users needs. Evidence that an assessment of service users requirements has been conducted must be form part of the care plan. Furniture and furnishings in the home must be of an acceptable standard. In a number of bedrooms bed bases were split and armchairs had holes in the covers. Bedside tables and chests of drawers were missing veneer, were stained and faded. Lighting within the home must be in full working order The proprietor must ensure that all radiators are covered to protect service users from risk of scalding or burns. This has been brought forward from the previous inspection and an Enforcement Notice has been served. References and application forms for staff recruited by an agency must be held on site. Evidence that a CRB check has been conducted for the proprietors wife must be sent to CSCI. The light switch with the do not use sign on must be investigated and made safe. Fire doors must not be wedged open and a safe , appropriate alternative approved by the Fire Safety Officer employed. The conservatory must be a comfortable temperature and appropriate measures taken to ensure this e.g. blinds for the roof and effective means of cooling the conservatory. Fire instructions must clearly inform staff and service users of evacuation points as they have 31/07/05 31/07/05 13/06/05 20/06/05 13/06/05 13/06/05 13/06/05 Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 20 faded. 10. 11. 12. OP37 37 Information that relates to regulation 37 must be submitted to CSCI. 13/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP3 OP11 OP12 OP15 OP19 OP22 Good Practice Recommendations It is recommended that a separate assessment document is devised to identify service userss rather than using the care plan document for this purpose. Individual wishes regarding funerals should be recorded in care plans. Activies should be recorded to reflect the variety offered and likes and dislikes of service users. The bucket used to collect waste food should be moved from the dining room out of sight from service users whilst they are eating. An action plan outlining the maintenance and renewal schedule for the next 12 months should be submitted to the commission. An assessment on the environment should be conducted by an occupational therapist to ensure that the environment meets the needs of service users. This is especially relevant to the bathrooms. An extension should be fitted to the call bell in the quiet lounge to enable service users to summon assistance quickly. Lockable space should be fitted on vacation of individual rooms. Where lockable space is declined a record should be kept in individual care plans. Pedal bins should be in place to ensure infection control is observed. An alternative should be explored to ensure that clinical waste is not carried through the home. Paper towels should be in place in place of terry hand towels for staff use. A change in rota is recommended to provide staff with a scheduled handover. Staff goodwill is expected currently to ensure that vital information is handed over between I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 21 7. 8. 9. OP22 OP24 OP26 10. OP27 Westbourne 11. OP30 shifts. The planned training and supervision schedule for staff should be submitted to the CSCI. Westbourne I52 s19611 Westbourne v224232 090505 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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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