Inspection on 26/06/07 for Westbourne House

This inspection was carried out on 26th June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbourne House 09/06/09

Westbourne House 16/06/08

Westbourne House 09/01/06

Westbourne House 13/04/05

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 Michael O`Neil Key Unannounced Inspection 26th June 2007 09:00 Westbourne House DS0000060015.V330676.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.V330676.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.V330676.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 none none 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.V330676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 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.V330676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil and Sue Turner, regulation inspectors. This visit took place between the hours of 09:00 and 13:15. The inspection was carried out the day after severe floods hit Sheffield and the home, although undamaged, was without electicity. Despite the home being without power for nearly 24 hours the inspectors found the staff and residents in relatively high spirits and welcomed the inspectors into their home. Kathleen Wigfull, manager, was present during the inspection. The manager submitted a pre inspection questionnaire to the CSCI prior to the actual visit to the home. Some information from the questionnaire is included in the main body of the report. The CSCI sent out questionnaires asking health professionals, residents, relatives and staff about the care and the service provided. There was a positive response and the CSCI received 3 health professional, 3 staff and 4 resident questionnaires back. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 2 staff and 4 residents. The inspectors wish to thank the staff and residents for their time, friendliness and co-operation throughout the inspection process. A copy of the previous inspection report was displayed and available in the foyer of the home. Information about how to raise any issues of concern or make a complaint was on display in the foyer. What the service does well: Residents spoken with felt that they had a reasonable amount of control over how they spent their time at the home and could choose when to get up, when to go to bed and what activities to be involved in, including leisure activities. Care records identified that there was good liaison with other healthcare professionals. Staff interviewed showed a good knowledge of the residents health and social needs. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 6 Health care professionals said that staff at the home communicated well with them and felt that the standard of care delivered at the home was good and said the staff at the home were very caring. Residents said that if they had any concerns that they would feel comfortable in talking to the manager, Kath, and they knew that the problems would be sorted out immediately. The home was clean and tidy. Bedrooms checked were comfortable and homely. There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Residents and staff said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. What has improved since the last inspection? What they could do better: The resident care plans must be improved to ensure that all staff know what to do to meet the resident’s changing mental and physical health, social and personal care needs. Medication storage needs to be improved so that medicines are safely stored in the home. To maintain resident and their own safety staff need to receive up to date fire training including the participation in fire drills. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 7 So that satisfactory standards of food hygiene are maintained all staff and residents should wear protective clothing when accessing the kitchen and should not use the kitchen as a thoroughfare. 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.V330676.R01.S.doc Version 5.2 Page 8 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.V330676.R01.S.doc Version 5.2 Page 9 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): Standards 2 and 4. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Full assessments take place to ensure the service is suitable and residents have the opportunity to visit the home prior to their admission. EVIDENCE: Three care plans were checked. These contained detailed assessments of the residents’ needs and how the proposed service at Westbourne House would be able to meet these needs. The assessments included full consultation with placing professionals and, where appropriate, residents relatives. One resident spoken with confirmed that he had been able to visit the home prior to moving here and that he had been helped to settle in when he arrived. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 10 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): Standards 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents said they were aware of their care plans and said that staff helped them to maintain as much independence in their lives as possible. However the three care plans checked were of a poor standard and did not reflect the changing needs of the residents, meaning that residents could not be fully informed and involved with their care. EVIDENCE: Three resident care plans were checked. The standard of the care plans were not satisfactory, and the information in them, was inadequate to ensure that the resident’s changing mental and physical health, social and personal care needs could be met. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 11 • The care plans and risk assessments in the resident files had not been reviewed by the staff on a regular basis. Reviews had not taken place in the care plans from between 3 months and over 2 years. A residents specific social, dietary and health needs had not been recorded as problems needing staff interventions or staff support despite staff being aware of the residents needs and wishes. Staff, when writing the residents daily notes, were not being reflective of the information actually recorded in the residents care plan. Staff were, on a number of occasions only recording a social activity that the resident may have participated in. There was some evidence to suggest that the resident or had been involved in the drawing up or the reviewing of the care plans, however this was over 6 months ago. • • • The inspectors discussed the shortfalls in the care plan documentation with the manager and advice was given on how to improve the care plans for each resident. Residents said that generally they were involved in making decisions about their own lives. The manager and support staff had considered if there were any restrictions on freedom and choice for each person, and kept a record of this with the residents’ information. The manager said she reviewed this as and when their needs changed. In the main each resident had good risk assessments in their plans, however as highlighted above these assessments were not being evaluated frequently enough. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have the life style and daily routines they want. This allows them to be independent and follow their wishes. EVIDENCE: Resident care plans contained information about how they could be involved in the community. These included using local facilities such as shops, pubs and the local shopping centre. Residents said that a new minibus had been purchased by the home and they were looking forward to going on more trips out of the home. The GP surgery is also close at hand and one resident said they could visit the G.P when they needed to. One resident spoken with said they visited a day centre. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 13 Residents spoken with felt that they had a reasonable amount of control over how they spent their time at the home and could choose when to get up, when to go to bed and what activities to be involved in, including leisure activities. Generally, routines appeared to be flexible and some residents were having drinks and breakfast at varying times on the day of the inspection despite the power cut at the home. Residents thought that the food, prepared by the support staff, was good and said they also helped in some day-to-day housekeeping tasks at the home which they enjoyed doing. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive good support for their personal and health care needs. A medication storage procedure provided a risk to the residents’ health and welfare. EVIDENCE: All residents said that the staff met their personal and healthcare needs. Care records identified that there was good liaison with other healthcare professionals, including GPs, community nurses and hospital-based staff. Prescribed treatments had been incorporated into the care plans where necessary. Staff interviewed showed a good knowledge of the residents health and social needs. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 15 Health care professionals said that staff at the home communicated well with them and felt that the standard of care delivered at the home was good and said the staff at the home were very caring. No residents currently manage their own medication. The medication was stored appropriately in the home, in a locked cupboard. All labels were intact on bottles and boxes and these could be clearly read. All medications seen were for named individuals currently at the home. The MAR (medication administration record) sheets were fully completed. Handwritten entries for medications prescribed in-between monthly deliveries appeared to accurately reflect prescription information but had not been signed by the person making the entry, or countersigned by a witness, to show they had been checked and confirmed as accurate. Medication controlled under the Misuse of Drugs Act was not being stored in an appropriate cupboard. It seems that there was some confusion at the last inspection as to the actual medication requiring specialised storage, however this was made clear at this inspection. A lockable metal cupboard must be fitted in accordance with guidelines, for the safe storage of controlled drugs. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures are in place to enable residents and relatives to feel confident that any concerns they voice will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure residents are protected from abuse. EVIDENCE: Complaints procedures were displayed in the home. Residents said that if they had any concerns that they would feel comfortable in talking to the manager, Kath, and they knew that the problems would be sorted out immediately. Staff interviewed had received training on adult protection and were aware that there were procedures in place to report any concerns. There was regular staff training on the protection of vulnerable adults. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 17 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): Standards 24, 25 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a homely, clean and comfortable environment. EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished to a good standard and felt “homely”. Bathrooms were clean and bright. Bedrooms checked were comfortable and homely. No unpleasant odours were noticeable in the home. Residents said that the home was always kept clean. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 18 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): Standards 32, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents get good support from staff who are trained and competent. Recruitment procedures promoted the protection of residents. EVIDENCE: The manager said that the required 50 of care staff had achieved their level 2/3 NVQ qualification. A sample of staff files checked identified that staff had achieved their NVQ qualification. Two members of staff interviewed said they had completed their NVQ training. The recruitment records of 2 recently employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made. Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 19 There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Staff files checked identified that staff had received induction training when they commenced work. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 20 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): Standards 37, 39 and 42. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a positive style of management in the home. This would have a positive affect on the quality of the service the residents receive. Some of the homes procedures did not fully promote the health, safety and welfare of residents and staff. EVIDENCE: The home’s manager is very experienced in the care setting and demonstrated a good knowledge of the residents needs. Throughout the inspection, the Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 21 impression was that the staff were committed to supporting and enabling the residents to lead fulfilling lives. Residents and staff said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. The home had an active quality assurance system. There was evidence that the home had sought information about the quality of the home from health professionals, relatives and the residents of Westbourne House. The home handles money on behalf of some residents. Account sheets were kept and receipts were seen for all transactions. Certificates were seen to show that the homes utility services had been serviced and maintained. (Previous requirements met) Practice fire drills had been conducted in the home and the records identified the length of the drill, the time the drill was held and any corrective action taken after the drill had been completed. However only 4 staff had participated in a fire drill in the last year. Staff said they had received recent fire safety and other health and safety training .A sample of records, however showed that three staff had not received any fire safety training for over 2 years. (Previous requirement) Staff and residents were observed using the kitchen as a thoroughfare to access other parts of the home. Advice was sought from an environmental health officer who said, “All staff and residents should wear protective clothing when accessing the kitchen and should not use the kitchen as a thoroughfare”. At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the residents. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 22 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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. Resident care plans and risk assessments must be reviewed at least every six months. Care plans must be reviewed and evaluated to ensure they identify the changing health, social and personal care needs of the residents. The residents daily notes must reflect the information actually recorded in the residents care plan. A lockable metal cupboard must be fitted in accordance with guidelines, for the safe storage of controlled drugs. (Previous requirement) Staff must receive up to date fire training including the participation in fire drills. (Previous requirement) Timescale for action 01/10/07 2. 3. YA6 YA6 15 15 01/10/07 01/10/07 4. YA6 15 01/10/07 5. YA20 13 01/09/07 6. YA42 23 01/08/07 Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 24 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 YA42 Good Practice Recommendations Suitable arrangements should be implemented to maintain satisfactory standards of food hygiene at the home. Westbourne House DS0000060015.V330676.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 House DS0000060015.V330676.R01.S.doc Version 5.2 Page 26 - 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. 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