CARE HOME ADULTS 18-65
Westbourne House 42/44 Dykes Hall Road Sheffield South Yorkshire S6 4GQ Lead Inspector
Shirley Samuels Key Unannounced Inspection 16th June 2008 10:00 Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 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 House DS0000060015.V364929.R01.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 Adults 18-65. 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 House DS0000060015.V364929.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Westbourne House Address 42/44 Dykes Hall Road Sheffield South Yorkshire S6 4GQ 0114 234 8930 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) Support Care Ltd Mrs Kathleen Wigfull Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th June 2007 Brief Description of the Service: Westbourne House is a care home providing personal care and accommodation for 11 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 initially 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 we gardens that are accessible for service users. The manager confirmed that the range of monthly fees from 26th June 2007 were £291 - £318 per week. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means people who use the service experience adequate quality outcomes.
This was a key inspection carried out by Shirley Samuels on Monday16/06/08 10am-3:45pm In the report we make reference to “us” and “we”, when we do this we are referring to the inspector and the Commission for Social Care Inspection. The inspector sought the views of eight people using the service, two staff and the registered manager, Kath wigfull who assisted with the inspection. This visit was a key inspection and the inspector checked all the key standards. During this visit we looked at the environment, and made observations on the staffs’ manner and attitude towards people. We checked samples of documents that related to peoples support, care and safety. These included three assessments and care plans, three medication records, and three staff recruitment files. To help make a judgement about the standard of the service we looked at the information provided in the Annual quality assurance assessment (AQAA), which was provided before the visit. In the AQAA we were given details of how the service met the needs of the people using the service and how the service planned to improve the outcomes for people over the next 12 months. The inspector would like to thank everyone for their welcome and help in this inspection. What the service does well: Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 6 People have their needs assessed before they move into the home this made sure that the staff had the information they need to make a judgement about whether they can meet a persons needs. People are able to make decisions about their lives and are supported to take reasonable risk. This encourages an independent lifestyle. People took part in educational and occupational activity such as computer courses and attending daycentres for recreational activities. Shops, pubs and clubs were close by and people used them on a regular basis. This made sure they were part of the local community. People told us they were able to keep in touch with family and friends. The daily routines of the home included the people who lived there and people were aware of their responsibilities for helping around the home and supporting each other. People told us in the main they were happy with the meals provided. People were able to make drinks and had access to fruit biscuits and other light snacks that they could help themselves to. People spoke positively about the staff and of the care and support they received. There is evidence from what people told us and from records that people’s health care needs are met. People are offered personal and emotional support according to their needs. People told us they have someone to talk to if they have any complaints. People felt safe and staff had received training on safeguarding adults. This made sure that people were protected from harm and staff knew what to do if an allegation of abuse was made to them. The home was reasonable maintained. Since the last inspection lounge and dining areas had been redecorated. The manager said there was a maintenance plan in place that included refurbishment of the bathroom and redecoration and replacement of furniture in people’s bedrooms. Procedures used to recruit staff made sure people were protected from harm. Staff told us they worked well as a team and they received training to help them understand the individual needs of the people they supported. People using the service and the staff spoke positively about the manager and of the way the home was run. People were consulted and asked to comment on the service and encouraged to suggest ways of how the service could be improved. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 7 There were procedures in place to make sure the home is run in a way that promoted the health and safety of the people using the service and of the staff. What has improved since the last inspection? What they could do better:
Records made following the review of care plans need to include the opinions and comments of the person using the service. Where incidents happen which highlight a risk to people using the service a risk assessment must be completed detailing the action to be taken by staff. Records of complaints must be kept detailing the complaint and the action taken. Improvements have been made to the standard of daily recordings of care given however this needs to be further developed. The medication procedures must include the recording of all medication received into the home and details of when new stock is commenced. Staff must make sure that people using the service sign for any money given to them and a second staff member witnesses this. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 8 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 House DS0000060015.V364929.R01.S.doc Version 5.2 Page 9 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 Outcomes Statutory Requirements Identified During the Inspection Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are assessed before moving into the home. EVIDENCE: Three peoples records were checked they all contained an assessment carried out before they moved into the home. This made sure that staff had the information they need to decide whether they could meet a persons needs. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7and 9 People who use the service experience Adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People had a care plan that detailed their needs. They were able to make decisions about their life and take reasonable risk. EVIDENCE: Each person had a care plan that detailed their needs and the action the staff needed to take to support them. People told us they were involved in writing their care plan. This means that people were able to have control and able to say what they wanted. Care plans were reviewed monthly but they did not include comments and the opinions of the people using the service. People told us they were able to choose how to spend their day. They said that staff gave them information about activities and things they could get involved in.
Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 12 Some people were responsible for the management of their own finances. Accounts were managed by the home for some people in the main the records were correct and the money stored balanced with the account sheet. There was one example of money not tallying with the account sheet. The manager said money had been given to the person using the service and a signature had not been obtained. We checked with the person who confirmed that they had received the money. People told us about how they were involved in the routines of the home. These included, washing pots, doing their own laundry, setting tables for meals, and clearing tables after meals. Some people talked about cleaning their own bedrooms with support provided by staff as and when needed. This promoted independence and developed daily living skills. People were supported to take reasonable risk. Written risk assessments were in place to cover risks as they were identified. There was one example of identified risk not being fully recorded detailing the action staff needed to take to reduce the risk of harm. People told us that staff talked to them about how to stay safe when out alone. People let staff know when they were going out, where they were going and what time they could be expected back. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 and 17 People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Education and meaningful activities was encouraged. People were able to maintain Contact with family if this was what they wanted. People were offered a healthy diet that they enjoyed. EVIDENCE: People told us they were able to take part in activities of there choice. They attended art club, daycentres, went swimming attended computer classes, church services, day trips and went on holidays. People told us they were comfortable going out on their own. They were familiar with the local community and used the shops clubs, local pubs and other amenities. This made sure that people were able to be part of the local community.
Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 14 Some people chose to spend most of their time in their bedroom knitting, reading and listening to music. The staff respected this preference this means peoples rights are respected. People told us they were able to keep in touch with family and friends and to develop personal relationships if they wished. The home had a domestic style kitchen. The staff have received training in food hygiene and are able to tell us about the people who are on alternative diets and how the home made sure people received the food they preferred and needed for health reasons. People told us they were happy with the food provided. They were offered choices and were asked about the food they liked. Menus were displayed so people knew what to expect and were able to say if they wanted an alternative. Everyone ate together and said the mealtimes were fun and relaxed. Records were kept of the food provided and details of special diets were recoded in care plans and in the kitchen. This meant that diets could be monitored. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People were supported in the way they preferred and their health care needs were met. There were some shortfalls in the medication procedures. EVIDENCE: Many of the people using the service told us they were able to attend to the majority of their personal care needs. For those who needed assistance from staff they told us staff were sensitive and respected their dignity. Staff told us they encouraged people to do what they could for themselves and offered assistance and support when it was needed. People went shopping for clothing and choose what they wanted to wear on a daily basis. People were well groomed. Personality and individualism was reflected in people’s choice of clothing hairstyles and makeup. The home had a key worker system people were able to tell us who their key worker was and how they were supported. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 16 Records showed that people attended appointments with optician, dentist chiropodist and other health care professionals. People were supported and escorted to attend appointments. People told us they were well looked after and their health car needs were met. There was evidence to show that were staff had concerns about peoples health they were promptly referred to appropriate specialist. Records were seen of appointments with health care professionals and the outcomes. This shows that people’s health care needs are met. The home had a medication policy. Staff responsible for administering medication had received training and their practice monitored by the manager. People told us the staff administered medication to them at the times they expected it. This means that staff have the skills and knowledge to administer medication safely. Controlled drugs were administered since the last inspection appropriate storage has been fitted for the storage of controlled drugs. Records of medication administered were kept. The medication cupboard was clean and tidy. Records of medication received into the home was not made and records were not kept to show when a new bottle or box of medication was started. This meant that accurate stock taking of medication was difficult to monitor. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and23 People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Complaints were taken seriously and people were protected from harm. EVIDENCE: People told us they had someone to talk to if they had a complaint. In each of the files there was a service user guide, which detailed the complaints procedure. Records of complaints were kept. The last complaint recorded was in 2004. Staff and people using the service told us they sorted out any “niggles” as and when they arose. These little “niggles” were not recorded. Staff had received training in safeguarding adults. Staff were able to tell us what action they took on a daily basis to protect people from harm. People told us they felt safe at the home and that the staff always looked after them spoke to them in a proper manner and were “Kind and patent”. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The home is well maintained clean and hygienic. EVIDENCE: Since the last inspection the lounges had been decorated and the carpets replaced. The home was clean tidy and homely. People told us they were happy with their bedrooms and were able to choose colour schemes at times of redecoration. This means that people live in a comfortable and safe environment. The manager told us that there was a refurbishment plan in place for some of the bedrooms and a bathroom. Staff told us they had received training on infection control and gave examples of how they maintained a clean hygienic environment. They said that gloves aprons hand gels and appropriate cleaning materials and equipment was
Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 19 available at all times. This means that good standards of hygiene are maintained. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, and 35 People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Staff are trained and competent to do their job and people are protected by the homes recruitment procedure. EVIDENCE: Staff told us they received training and guidance to support them in the job they do. They told us they received training to help them understand specific conditions of the people they support. This means they are able to respond appropriately and give people the support they need. Each member of staff had a training plan and records were kept of all the training attended. People told us the staff are very “supportive”. The majority of the staff are trained to National Vocational Qualification (NVQ) level 2. The staff said the team worked well together, they enjoyed their work and felt they provided a good service to a high standard.
Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 21 Appropriate checks were made on staff before starting work at the home. There was a file for each member of staff these contained evidence that checks had been carried out including criminal records, health checks and references. This means that the recruitment procedures protected people from harm. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The home is well run, people are able to comment on the quality of the service and the health safety and wellbeing of people is protected. EVIDENCE: The manager is competent and qualified to manage the home and has many years experience. The staff and people using the service spoke positively about the manager and her approach and commitment to promoting a good service and supporting people using the service as well as the staff. People told us they were asked to comment on the standard of he service and how it could be improved. Staff told us they to were consulted and felt they were able to contribute to the way the home was run. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 23 Staff also said the Responsible person and the owners were approachable, caring and showed a keen interest in peoples experience of the service. This means that the home is run in the best interest of the people using the service. Staff told us they had received Health and safety training. There were procedures in place to make sure safety issues were addressed quickly. There was a fire risk assessment in place and staff had received fire instruction. The records showed that the fire system and fire fighting equipment was check regularly. Observation on the day of the visit showed that staff carried out their duties in a safe way and staff understood their responsibility for the safety of the people using the service and for themselves. This made sure that peoples safety health and welfare was protected and promoted. Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 24 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. 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Westbourne House DS0000060015.V364929.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement Reviews of the care plans, when they take place, must include the wishes and opinions of the residents or their advocates. Previous time scale 01/10/08 improvement but not fully met The residents daily notes must reflect the information actually recorded in the residents care plan. Previous timescale 01/10/08 improvement but not fully met. Timescale for action 01/09/08 2 YA6 15 01/09/08 3 YA7 17 Schedule 4 4 5 YA9 YA20 15 13 Where the home is managing 01/09/08 people’s money, staff must make sure that people sign for any money given to them and a second member if staff must witness this. As part of a care plan. Where a 01/09/08 risk is identified a written risk assessment must be completed. A record must be kept of all 01/08/08 medication received into the home and of when new stock is commenced. A record of all complaints must be kept.
DS0000060015.V364929.R01.S.doc 6 YA22 17 Schedule 01/08/08 Westbourne House Version 5.2 Page 26 4 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 House DS0000060015.V364929.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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
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