Inspection on 13/04/05 for Westbourne House

This inspection was carried out on 13th April 2005.

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 House 09/06/09

Westbourne House 16/06/08

Westbourne House 26/06/07

Westbourne House 09/01/06

Westbourne House 24/11/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Westbourne House 42/44 Dykes Hall Road Sheffield South Yorkshire S6 4GQ Lead Inspector Jayne Barnett-Middleton Unannounced 13th April 2005 09.30 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House Version 1.10 Page 3 SERVICE INFORMATION Name of service Westbourne House Address 42/44 Dykes Hall Road Sheffield S6 4GQ 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) 0114 234 8930 0114 232 6314. None Support Care Limited Mrs Kathleen Wigfull PC Care Home Only 10 Category(ies) of MD Mental Disorder registration, with number of places Westbourne House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th November 2004 Brief Description of the Service: Westbourne House is a care home providing personal care and accomodation for 10 people. The home is registered for adults between the age of 18 and 65 who have mental health needs .The home is owned by support care services who also provide the care. Westbourne House is situated close by to Hillsborough shopping centre, it is ideally located for access to local amenities. The home was initiailly registered in March 1997 and consists of two houses adjoining, with internal access to each home and an extension at the back with garden and grounds. The home is on two levels and does not have lift access to the second floor. All the bedrooms are single; the bedrooms do not have ensuite facilities. The home has a car park and well-maintained gardens that are easily accesible for service users. Westbourne House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 9.30 a.m to 1 p.m. Six service users, three staff, the registered manager, the responsible individual and one visiting healthcare professional were spoken to. A sample of records were examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The inspector wishes to thank the manager, staff and service users for their time and co-operation throughout the inspection process. What the service does well: The home has a warm, friendly and welcoming atmosphere. Service users were relaxed and happy to talk about the care that they received. Service users said that they were highly satisfied with the care provided All service users were encouraged and supported to live as independently as possible Daily routines were flexible and service users were encouraged to spend their day as they wished. The manager and staff had an excellent knowledge of service users individual needs and abilities. Through discussions and observations it was evident that service users were encouraged and supported to make decisions relating to their own lives Service user meetings were held every two weeks, which enabled service users to contribute to the running and organisation of the home. A good choice of menu was offered which catered for the dietary needs of service users. Service users said that the food was “very good”. Service users said that their healthcare needs were met .The healthcare professional spoken to stated that the service users were very well cared for. She confirmed that the staff team worked very well to ensure that the physical, emotional and healthcare needs of service users were met. The home was very well maintained. Several areas had been redecorated, new carpets provided and a bathroom had been refurbished to a very good standard. There were plans to refurbish the remainder of the home. All areas throughout the home were very clean and it was evident that the manager and staff team took pride in creating a homely environment for service users. All staff had received training that included adult protection, mental health, and personal care. The manager of the home had many years experience in the caring profession and was clearly able to demonstrate the individual needs of service users. The Staff said that the manager and the responsible individual were approachable and supportive, which promoted a good working atmosphere and provided clear leadership Westbourne House Version 1.10 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne House Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Westbourne House Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2. Prospective service users and their relatives were provided with the information that they needed A full needs assessment was carried out. EVIDENCE: A Statement of Purpose and Service Users Guide were available, these provided service users and their relatives with the information that they needed to make an informed choice about living at the home. A full needs assessment was carried out for all service user prior to their admission. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate a individual plan of care. Westbourne House Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. Service users individual needs were assessed and their changing needs were reflected in their plan of care. Service users were encouraged and supported to live as independently as possible. Service users were offered the opportunity to contribute to the quality of service that they received. . EVIDENCE: Two Care plans were checked and they set out in excellent detail the action that was required by staff to ensure that all aspects of service users personal, social support and healthcare needs were met. The Care plans had been completed with the involvement of the service user, which gave them the opportunity to agree with staff the help that they needed to live as independently as possible. Through discussions and observations it was evident that service users were encouraged and supported to make decisions relating to their own lives. Service users confirmed that they were able to spend their day as they wished. Several had chosen to spend their day at the home and were socialising with other service users in the lounges. One service user was spending time in her bedroom. Two service users had chosen to go out for the day. Westbourne House Version 1.10 Page 10 Service user meetings were held every two weeks, which enabled service users to contribute to the running and organisation of the home. Service users said that they found the meetings very useful and that it gave them the opportunity to discuss the choice of food that was offered, suggest places to visit for days out and to discuss with the staff any concerns that they may have. Service users were encouraged to manage their own finances, which enabled them to maintain their independence and to spend their money as they wished The manager said that the majority of service users managed their own monies. Two service users who were in need of help to manage their monies were supported by the staff at the home. Service users files contained detailed risk assessments relating to all aspects of service users lives both inside and outside the home. They clearly identified the individual risks that were presented to service users on a daily basis and the action required to reduce the risk, which enabled service users to live an independent lifestyle. Westbourne House Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14,15,16 and 17. Service users were maintaining and developing social and independent living skills. Opportunities were provided for service users to engage in activities within the home and maintain links within the local community. Service users were offered a healthy and varied diet. EVIDENCE: Service users had responsibility for some housekeeping tasks, which included setting tables for mealtimes and washing their own clothing. A household rota had been agreed. The service users said that they “ worked as a team” and that the rota worked very well. Service users confirmed that they took part in activities within the community, which included attending day centres and visiting the local shops and park. Appropriate leisure facilities were provided within the home. Service users were observed to be watching television and the manager said that regular events such as quiz nights and bingo were held. The manager had recently introduced a weekly social evening for service users, which service users said that they enjoyed. Two service users confirmed that they maintained good relationships with their families and that they were welcome to visit them at any reasonable time. Westbourne House Version 1.10 Page 12 Service users said that their privacy was respected. One service user said that she enjoyed spending time in her bedroom and that the staff respected her choice. Service users said that they were able to visit the shops independently if they wished and that the staff would escort them if they needed help or support. Locks were fitted to bathroom and bedroom doors, which promoted the privacy of service users. The inspector observed that the home promoted independence, individual choice and freedom of movement by encouraging service users to spend their day as independently as possible. Service users were offered and encouraged to eat a healthy diet. A good choice of menu was offered which catered for individual dietary needs. The cook said that menus were reviewed on a regular basis in consultation with service users, to enable them to agree the choice of meals that were offered. Service users said that the food was “very good”. The cook said that service users were able to assist in the kitchen if they wished to maintain their independent living skills. One service user described how she enjoyed baking and how the cook assisted her in doing this. A small kitchenette was provided for service users should they choose to make a snack or drink in addition to mealtimes. Westbourne House Version 1.10 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20. Service users received personal support, which promoted their privacy, dignity and independence. Service users physical and emotional needs were met. EVIDENCE: The manager said that service users received excellent support from healthcare professionals who visited them. Service users said that their daily routines were flexible. They confirmed that they could get up and go to bed when they wished and that the staff would assist them with their personal care if they needed help. Each service user was assigned a key worker to ensure that service users, where possible, were able to receive care and support from the same member of staff. There were records to evidence that service users were receiving regular visits from their general practitioner, dentist and other healthcare professionals. The care plans set out in detail how service users preferred to spend their day and their likes and dislikes. Service users said that the staff would make health care appointments on their behalf if needed. Service users said that their healthcare needs were met and were able to confirm healthcare appointments that they had attended. The healthcare professional spoken to stated that the service users were very well cared for. She confirmed that the staff team worked very well to ensure that the physical and emotional needs of service users were met. Westbourne House Version 1.10 Page 14 There was a medication policy and procedure to ensure that staff adhered to safe practices. The recording and storage of medication was checked on a sample basis, staff had received medication training; all promoting that medication was appropriately administered to service users. Service users had been consulted about staff assisting them with medication, risk assessments had been carried out to identify if service users could administer their own medication. Westbourne House Version 1.10 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure. and all staff had received adult protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Service users stated that they were satisfied with the care provided. They confirmed that they had no complaints, however they would speak to the manager or staff should they have any concerns regarding any aspect of their care. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff confirmed that they had received adult protection training which enabled them to identify and report any allegations or incidents of abuse to service users. The manager has obtained copies of adult protection procedures including local policy and the Department of Health guidance, No Secrets, to ensure that staff are familiar with adult protection procedures. Westbourne House Version 1.10 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27 and 30. The home was clean, comfortable and very well maintained. Service users were provided with an environment that met their individual needs and lifestyles. EVIDENCE: The home was very well maintained. Several areas had been redecorated and one bathroom had been refurbished to a very good standard. Service users said that they liked the home and that it was homely and comfortable. The furniture and fittings were clean and of a good quality. The manager and owner said that they intended to continue to redecorate and refurbish communal areas and bathrooms within the home. Several bedrooms were checked and all were clean, tidy and pleasantly decorated. One bedroom had a broken light fitting which created a potential safety risk Service users had personalised their bedrooms with ornaments and mementoes which created a homely environment. Service users said that they liked their rooms. All areas throughout the home were very clean and it was evident that the manager and staff team took pride in creating a homely environment for service users. Westbourne House Version 1.10 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 and 36. An effective staff team supported service users. All staff received training and support appropriate to their role. The home operated a thorough recruitment policy that promoted the protection of service users. EVIDENCE: Staff had a good understanding of their role and were able to describe how they supported service users in their daily lives. All staff had been issued with the homes statement of purpose, which ensured that they had a good understanding of the homes values and philosophy of care. All staff had received training that included adult protection, mental health, and personal care. The manager confirmed that four staff held an NVQ qualification, which developed the skills and competence of staff, to enable them to meet the changing needs of service users. Staffing levels were being maintained. Two staff for the morning and evening shifts and one waking night staff were provided. Service users and staff said that there were sufficient staff on duty to help them. Westbourne House Version 1.10 Page 18 A thorough recruitment policy and procedure was in place that promoted the protection of service users. Two staff files checked contained a range of required information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. A system was in place to ensure that any agency staff working at the home had undertaken a criminal records bureau check and to confirm that they had received the appropriate training to safely care for service users. Staff received regular supervision that gave them the opportunity to focus on care practices and to identify any training and development needs. The records sampled evidenced that staff were receiving supervision on a consistent basis and that topics such as the philosophy and aims of the home were discussed. Westbourne House Version 1.10 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, and 42. Service users benefited from a well run home. The management approach of the home promoted a positive and relaxing atmosphere. The home was well maintained and safe for service users. Staff were conversant with health and safety policies and procedures which promoted the health, safety and welfare of service users. EVIDENCE: The manager of the home had many years experience in the caring profession and was clearly able to demonstrate the individual needs of service users. The Staff said that the manager and the responsible individual were approachable and supportive, which promoted a good working atmosphere and provided clear leadership. Staff said that they all worked very well as a team, which provided service users with a consistent quality of care. The manager confirmed that she had attended various training courses to maintain and update her knowledge of the service, and that she was in the process of undertaking a NVQ level 4 qualification in management and care. Westbourne House Version 1.10 Page 20 Staff and service user meetings were held on a regular basis, which provided them with the opportunity to contribute to the day to day running of the service. Service users were relaxed and there was an informal and friendly atmosphere within the home. The records sampled were very well organised, up to date and securely stored in accordance with the data protection act. The staff had received regular training to promote the health, safety and welfare of service users and their colleagues. Staff were scheduled to undertake refresher first aid, food hygiene and health and safety training to ensure that they were up to date with safe working practices and legislation. Westbourne House Version 1.10 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 2 x Westbourne House Version 1.10 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. 1. Standard YA 42 Regulation 23 Requirement The light fitting in the identified bedroom must be replaced. Timescale for action 1st May 2005. 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. Refer to Standard YA 32 Good Practice Recommendations 50 of care staff (including agency staff) should achieve a National Vocational qualification in care at least level 2 or above by 2005. Westbourne House Version 1.10 Page 23 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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 Westbourne House Version 1.10 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!