Inspection on 09/06/09 for Westbourne House

This inspection was carried out on 9th June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC 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 16/06/08

Westbourne House 26/06/07

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 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Westbourne House 42/44 Dykes Hall Road Sheffield South Yorkshire S6 4GQ Lead Inspector Shirley Samuels Key Unannounced Inspection 9th June 2009 9:45 Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Westbourne House DS0000060015.V375753.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.V375753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2008 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 Fee was 307.50. Further information about the home can be obtained by contacting the manager. Westbourne House DS0000060015.V375753.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 the people using the service experience adequate outcomes “We have reviewed our practice when making requirements, to improve national consistency. Some requirements from the previous inspection may have been deleted or carried forward into this report as recommendations-but only when we consider that people who use the service are not being put at risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” What the service does well: What has improved since the last inspection? People told us they were consulted about their care plans and these were signed by people. Daily recordings contained a little more detail however further development is needed which the manager acknowledged. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 6 People’s financial recordings were appropriately kept and recoded all the required detail. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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.V375753.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using 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. The home did not obtain written assessments of peoples needs before they moved in. EVIDENCE: Since the last inspection two people have been admitted to the home. There files were checked and they did not contain written assessments. This means that the home admitted people without detailed written information. Found on one of the files was an old record from a previous placement giving a brief summary of the person’s needs and some comments gained from a relative. Reviews of the placements had taken place after two weeks two weeks and the outcome of these reviews was recorded. This means the home did not have all the information they needed to make a judgement about whether or not they could meet people’s needs and help them meet their aspirations. The home did not have the information they needed to build an acceptable care plan. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using 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. People’s needs were not fully detailed in their care plan they were able to make choices but options were limited and risk was not always identified and recorded. EVIDENCE: In the AQAA the manager told us that people had a care plan and that these were kept under review. Care plans seen were signed by people. Care plans included very general needs such as personal care, communication, mobility, continence and mental state. All these areas were relevant but the care plan lacked attention to the person as an individual. Care plans were not generated from an assessment as these were not in place. This means the care plan did not reflect individual needs goals aspirations and changing needs. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 10 People told us they were able to make choices about their daily life and activities. Staff told us they try to give people information to help them make choices and encourage independence. Activities are provided games, art, reading computer classes, swimming, going to the park shopping and gardening and going out with friends and family. In practice the options and choices presented to some people are limited this meant that people were making choices from a limited selection. Staff felt unable to seek out and introduce more varied and stimulating activities that are more relevant to younger adults. This would help people to live a more fulfilling life developed around their individual needs, wishes and potential. People told us they were able to take reasonable risk as part of an independent lifestyle. People were able to go out with friends, travel alone and prepare light snacks. 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 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. On the two files checked risk assessments were not in place prior to admission. Risk assessments did form part of the care plan. However daily notes recorded events that clearly had risks attached to them. These had not been identified as risks by the staff and risk assessments were not in place for these things. This could place people at unnecessary risk. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,15,16 and 17 People using 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 are some shortfalls in access to activities however people are part of the local community and are able to maintain contact with friends and family. The meals provided are healthy and people enjoy them. EVIDENCE: There was some evidence that some individuals took part in educational and occupational activities. This however was limited to a couple of people. For the majority access to education and occupation had not been fully explored or had been explored in the past and not revisited. This meant that some people did not have the opportunity to take part in age, peer and culturally appropriate activities. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 12 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. 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 people’s 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. 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. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People using 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. People are offered support and their healthcare needs are met. There are some shortfalls in the medication system. EVIDENCE: The majority of people using the service are able to attend to their own personal needs. People told us that if they needed support staff were really kind. 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. 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 Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 14 well groomed. Personality and individualism was reflected in people’s choice of clothing hairstyles and makeup. 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. 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. There was one example of the name of the medication being used on the medication administration sheet being different from the name on the box of medication. Although the staff said they had checked this and were assured by the pharmacist that it was the same medication. This could cause confusion and place people at risk. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using 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. Peoples views are listened to and the procedures from harm. EVIDENCE: The home has complaints procedure, and a file for recording complaints. There have been no complaints recorded since the last inspection. People told us they knew who to talk to if they were not happy. Staff told us they had received training on safeguarding adults and knew the procedures to follow for reporting allegations. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using 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. The environment is clean well maintained 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 garden areas have received attention since the last inspection people are able to plant flowers and vegetables. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 17 The manager told us that there was a refurbishment plan in place for some of the bedrooms and a bathroom. Staff gave examples of how they maintained a clean hygienic environment. They said that gloves aprons hand gels and appropriate cleaning materials and equipment was available at all times. This means that good standards of hygiene are maintained. Westbourne House DS0000060015.V375753.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 People using 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. Staff are trained and the recruitment procedures were safe. EVIDENCE: In the AQAA the manager told us that staff were trained to National vocational level 2 in care. This means they have the skills and knowledge to support people appropriately. Staff told us since the last inspection they had received training in diabetes, equality and diversity, safe handling of medication and specialist training for people working with people living with mental health problems. Staff told us that the organisation positive about training and allowing staff to attend. Each member of staff had a training plan and records were kept of all the training attended. The staff said the team worked well together, they enjoyed their work and felt they provided a good service. They acknowledged there was further development of the service needed to incorporate up to date practice around supporting people. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 19 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. Since the last inspection it has become the support staff role to prepare and cook meals. The majority of preparation and cooking takes place without input from people using the service. This task takes away a lot of the time that staff should be spending on direct support and contact with people using the service. Westbourne House DS0000060015.V375753.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People using 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. People tell us they are happy with the service but there are some shortfalls in opportunities for them, in the management of the service and maintenance of safe working practices. EVIDENCE: The manager is qualified to manage the home and has many years experience. There are however some shortfalls in meeting the homes stated purpose, aims and objectives. This means that people are not fully benefiting from a well run service. Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 21 The responsible individual makes regular visits to the home. However records of these visits evidence of discussion with people using the service and the staff were not available for inspection. 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. Staff also said the Responsible person and the owners were approachable, caring and showed a keen interest in people’s 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. The records showed that the fire system and fire fighting equipment was check regularly. However staff had not received fire instruction in the last six months. This was pointed out to the manager on the day of the inspection and she was required to ensure staff received instruction during their next shift on duty. 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.V375753.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 N/A 2 1 3 N/A 4 N/A 5 N/A 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 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 2 STAFFING Standard No Score 31 N/A 32 2 33 N/A 34 3 35 3 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 N/A 2 N/A LIFESTYLES Standard No Score 11 N/A 12 1 13 3 14 N/A 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 N/A 2 N/A 2 N/A N/A 2 N/A Version 5.2 Page 23 Westbourne House DS0000060015.V375753.R01.S.doc 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 YA2 Regulation 14 Requirement To make sure the staff have the information to make a judgement about whether they can meet people’s needs. The home must obtain a written assessment of people’s needs and aspirations before they move into the home. To protect people from unnecessary risk. Staff must have the skills to recognise risk, where this is identified a written risk assessment must be completed. Detailing what the risk is who is at risk and the action to be taken to reduce the risk. Risk assessments must be reviewed and kept up to date. To allow accurate monitoring of the medication system. Staff must record when new stock is commenced and the numbers of any medication carried forward. This part of the requirement is carried forward from 01/08/08 The name of the medication Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 24 Timescale for action 31/07/09 2 YA9 13 31/07/09 3 YA20 13 31/07/09 4 YA37 12 5 YA39 12 6 YA42 23 stated on the Medication box or bottle must match with the name on the Medication administration sheet. To make sure people benefit 31/07/09 from a well run service. The home must be managed in a way that meets its stated purpose, aims and objectives. To make sure the conduct of the 31/07/09 service is monitored. The responsible person must visit the service, talk to people and make a report of findings and actions needed. To promote the health and 31/07/09 safety of people using the service and the staff. All staff must receive fire instruction during their next shift on duty. 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 YA7 Good Practice Recommendations To make sure that people live a more fulfilling life that is developed around their individual needs, wishes and potential. Staff should seek out and introduce additional varied and stimulating activities that are relevant to younger adults. Staff should receive training in infection control. There should be a review of support staff responsibility for cooking meals. This responsibility should not detract support staff from providing direct contact and support to people. 2 3 YA35 YA31 Westbourne House DS0000060015.V375753.R01.S.doc Version 5.2 Page 25 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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