Inspection on 09/01/06 for Westbourne House

This inspection was carried out on 9th January 2006.

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 no outstanding requirements from the previous inspection report, but made 3 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 26/06/07

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 Mrs Sue Stephens Unannounced Inspection 9th January 2006 10:00 Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 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.V277171.R01.S.doc Version 5.1 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.V277171.R01.S.doc Version 5.1 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.V277171.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 2005 Brief Description of the Service: Westbourne House is a care home providing personal care and accommodation 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 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 well-maintained gardens that are easily accessible for service users. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between the hours of 10am and 4:30pm. Nine residents were consulted and they gave their views and opinions about the home. The inspector checked a sample of records including care plans, training and health and safety documents. A partial inspection of the home was carried out and the staff and manager were consulted. The manager assisted with the inspection. The inspector found the home to be inviting, with a warm and friendly atmosphere. Residents were noted to be relaxed and at ease and the staff were positive and helpful in their approach. The inspector would like to thank the residents, manager and staff for their kind help during this inspection. What the service does well: The residents said they were happy and settled living at the home. The manager and staff were respectful towards the residents’ needs and preferences and treated them with dignity and respect. The residents received good health, social and personal care. There was a lot of evidence that residents choices and preferences was respected and residents said they were involved in the running of the home. The manager had carried out a survey to find out what people thought about the home. And received positive feedback from residents and other professionals. There was good record keeping; the records were neat and orderly and up to date. The care plans were informative and held relevant information about individuals, including preferences and choices. Staff had received good training and training for the coming year had been identified. The manager and responsible individual took prompt action when it was identified that improvements were needed, for example following inspection or when raised by a resident. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 6 Residents were very satisfied with the homes environment. It was clean, warm and furnished in a comfortable and homely manner. There had been good investment and effort in improving the environment for the comfort of the residents. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 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 the following standard(s): 2 and 3. A full assessment of needs had been carried out for each resident; this led to the home meeting each resident’s needs and aspirations. EVIDENCE: Each resident had an assessment of need. The assessments had been reviewed using the homes own assessment tool. This assessment tool was adequate, however the manager said she was looking at ways of improving the assessments so that they would better identify the needs of residents. Staff respected residents’ preferred daily routines, they spoke to residents in a dignified and friendly manner, and continually monitored the residents’ wellbeing. A resident recently admitted to the home confirmed that he was offered trial visits before he was admitted. All the residents who spoke to the inspector said they felt they were very well cared for and they said staff knew how to look after them. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 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 the following standard(s): 6,7,8 and 9. The care plans supported good practices, and staff at the home respected people’s individual needs and choices. EVIDENCE: The care plans were up to date with relevant information. For example they included the individual’s preferences and daily routines, health information, family contacts, reviews and risk assessments. Residents could be involved in their plans if they wished. The residents told the inspector that staff respected the decisions they made, for example if they preferred to stay at home rather than go out. Residents were also involved in choosing day trips and holidays, and regular meetings took place for residents to discuss the running of the home. Residents ability to manage their own finances was assessed and support was given where needed, and in agreement with the individual. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 11,12,13,14,15 and 16 The residents were able to maintain a good life style and follow their own individual preferred daily routines and activities. EVIDENCE: The manager and staff understood the resident’s choices and preferences about daily activities. Some residents had reached or were beyond retirement age, and they chose a quieter life style, this was respected and the homes daily routines fitted around the residents. For example residents chose what time they got up and went to bed. They chose their own routines which included going for walks, shopping and local pubs. One resident attended college, and the home gave support and encouragement to the resident. Residents who wished to do so were involved in the cleaning and cooking at the home. Four residents told the inspector they were happy with their daily routines, and staff were available when they needed them. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 11 The manager was caring and sensitive about the residents preferred routines and encouraged but did not put undue pressure on residents to try alternative activities. The home is situated within a busy community, and the residents have access to all the local amenities, for example the park, shops, banks, leisure facilities and public transport. The resident could maintain links with their families and friends as they wished, this included visits to the home and outings. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 18,19 and 20 Residents’ received good health and personal care. Some medication systems need to improve in order to maintain residents safety. EVIDENCE: Residents said they were happy with the personal and health care support they received. They said staff were helpful and understanding and available to assist them when visiting; for example GPs or dentists. Residents were encouraged to maintain their independence. The care plans reflected this and included changes to health and personal needs. The inspector noted that residents were encouraged to be smart in their appearance, this included staff advising about appropriate and dignified clothing. One resident said staff gave him a lot of support and this mattered a lot to him. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 13 The home received regular pharmacy checks and had good links with the pharmacist for advice and support. In the main, systems for dealing with medication were in order, however the following areas for improvement were found. • • There were no assessments and risk assessments to assess the level of support each resident needs to take their own medication. Some administration signatures had been missed; for example it was not recorded clearly whether the medication had not been given, refused or some other reason. There was no metal lockable cupboard to keep controlled drugs in. • Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 22 and 23 The manager and staff listen to the views of the residents. The homes adult protection policies and training helps to protect the residents from harm. EVIDENCE: The home had a complaints policy. The procedure was on display in the entrance of the home and each resident had received a copy. Residents told the inspector they knew how to make complaints and they could raise concerns with staff or in meetings. Staff had received adult protection training and the policies and procedures were available at the home for staff to refer to. The inspector checked a sample of one resident’s finances; the records were in order. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 24, 25, 26, 28. The home was very well furnished and decorated in a manner that met residents’ needs and expectations. EVIDENCE: All residents consulted said they were happy with the homes environment. The home was clean, bright and had a homely atmosphere. Fittings and furnishings were of good quality and residents said they were warm and comfortable. It was evident that the manager and staff took pride in the homes appearance. There were new dining chairs and tables in the dining area and the manager had a plan for future renewals and decor. The home had made good improvements; for example redecorated bedrooms, old furniture replaced with comfy and homely designs, and a new fitted kitchenette for residents to use. These improvements benefited the residents. With the consent of the resident the inspector checked the new bedroom. The resident said he was satisfied with the fittings and furnishings. And had been informed about the size before he agreed to move into the home. (The room measurements were just below minimum standard measurements). Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 16 Shared spaces for example the dining area and sitting rooms were comfortable and well decorated. Residents had a choice of seating areas including a quiet area and smoking lounge. Space to meet with visitors in private was also available. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35. Staff training was suitable for the needs of the residents and contributed to the good standards of care provided at the home. EVIDENCE: Three out of eight staff had achieved a National Vocational Qualification in care, and one staff was working towards the qualification. To make sure the 50 NVQ target was met the inspector advised the manager to provide more staff with the NVQ training. Staff received good training opportunities, and each staff member had a training profile, this identified their training needs for the coming year. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39,40,41 and 42. The home was well managed and provided residents with a relaxed and pleasant place to live. Improvements in risk assessments and fire training will enhance the homes safety. EVIDENCE: Westbourne house had a warm, friendly and inviting atmosphere. Residents were positive about living at the home and said staff cared for them well. The home was relaxed and managed in a way that put residents dignity and respect first. For example residents set routines were respected and careful consideration was given to anything that may upset or worry the residents. Quality assurance systems were excellent. Surveys had been sent to residents, families and other professionals and their feedback had been acted upon. One feedback form stated the home gave “Excellent standard of care in a warm homely environment” and was the “best residential home”. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 19 Regulation 26 visits had taken place and these included consulting with residents. The home had updated their policies and procedures with a new system and the manager was working through the policies to make sure they fitted with the home. In the main records were very well maintained and orderly, however one document relating to electrical work had been lost. The manager confirmed she was taking action to replace the certificate. In the main the manager and staff followed good safe working practices, however the need for improvements in the following were found: • • • • The electrical fixed wire certificate could not be found. There was no risk assessment for the risk of legionella. Staff had not received up to date fire training. The home did not have a fire risk assessment. Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 20 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 3 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 3 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X 3 4 3 3 2 X Westbourne House DS0000060015.V277171.R01.S.doc Version 5.1 Page 21 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 YA20 Regulation 13 • Requirement Assessments and risk assessments to assess the level of support each resident needs to take their own medication must be carried out and regularly reviewed. Signatures confirming medication administered and the reason for missed medication must be recorded on all incidences. Timescale for action 31/01/06 • • 2 YA32 18 3 YA42 12 A lockable metal cupboard must be fitted in accordance with guidelines, for the safe storage of controlled drugs. A minimum of 50 of care staff (including agency staff) must achieve a National Vocational qualification in care at least level 2 or above. • The electrical fixed wire certificate must be replaced. • A legionella risk assessment must be DS0000060015.V277171.R01.S.doc 30/06/06 31/01/06 Westbourne House Version 5.1 Page 22 • • carried out. Staff must receive up to date fire training. A fire risk assessment must be carried out. 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.V277171.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sheffield Area Office 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 DS0000060015.V277171.R01.S.doc Version 5.1 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. 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