Inspection on 13/09/05 for Westbourne House Nursing Home

This inspection was carried out on 13th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westbourne House Nursing Home 21/10/08

Westbourne House Nursing Home 24/10/06

Westbourne House Nursing Home 19/01/06

Westbourne House Nursing Home 15/02/05

Westbourne House Nursing Home 08/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Westbourne House 379a Earl Marshall Road Sheffield South Yorkshire S4 8FA Lead Inspector Janice Griffin Unannounced 13 September 2005 09:00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westbourne House Nursing Home Address 379a Earl Marshall Road Sheffield South Yorkshire S4 8FA 0114 2610016 0114 2610020 Not known Palms Row Health Care Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Marcella Wilkinson N - Care home with nursing 71 Category(ies) of DE(E) Dementia - over 65 (20) registration, with number OP Old age (51) of places Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14th February 2005 Brief Description of the Service: Westbourne House is registered to provide nursing and personal care for 71 people with a range of medical and mental health needs. It is in the Fir Vale area of Sheffield, close to all local amenities. The home is based on 3 floors, a passenger lift is provided. A variety of communal areas are provided. The home is well maintained. Pleasant garden areas are provided with seating. The home has a car park. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 9:00 am to 14:45 pm. As part of the inspection process seven-service users, six relatives and five staff, including the manager, were spoken to. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with each service user who were obviously comfortable and at ease in the company of staff. The inspector would like to thank service users, relatives, the manager and staff for their commitment to the inspection process. What the service does well: The home is homely, friendly and welcoming. Service users said they liked living at the home where they were well cared for by staff. All areas of the home were clean and well maintained to a high standard. Service users were able to visit the home for trial periods and full detailed assessments had been completed prior to their admission. Service users were only admitted once it had been determined that the home could meet their needs and all service users currently living at the home were happy with the arrangements. Service user and relatives confirmed that they were able to talk to the manager and staff whenever they wished if they had any ideas or concerns. The personal and health care needs of each individual had clearly been identified and the manager and staff had worked positively and proactively to ensure that they addressed these needs. All service users attended a good variety of social and leisure activities and these were based very much on the personal preferences of each individual. Staff interacted well with each service user and it was obvious from discussions with service users and relatives that staff had developed positive and respectful relationships with them. Newly recruited staff had completed detailed induction training. Records were in the main well ordered and up to date and the manager was keen to ensure that any issues found were addressed. The manager and staff had completed a range of training courses and were committed to developing this further. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5. A detailed service user guide and statement of purpose have been produced and these clearly provided service users with the necessary information regarding the services and facilities provided by the home. Service users individual needs had been fully assessed prior to their admission, and they had moved into the home once it had been agreed that the home could meet their needs. Service users were able to have informal introductory visits to the home and at the time of their admission had been provided with a contract containing the relevant information Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 9 EVIDENCE: The statement of purpose and service user guide had been updated and they contained all of the required information. Copies were available and the manager confirmed that they would be available in alternative formats should the service users request this. Both documents were explained and read out to service users on a regular basis. Detailed full needs assessments had been completed by the referring social worker for service users admitted to the home. Their families had been involved in the assessment process as appropriate. The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home and made them feel less anxious. Records checked confirmed that service users families had been very involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10. Service users had their needs set out in an individual plan of care and their health care needs were fully met and regularly reviewed. Care plans had been fully completed and contained all the relevant information relating to each individuals needs. Service users said they were treated with respect and that their right to privacy was upheld, they also said that they were encouraged and supported by staff to make decisions and they were provided with informal opportunities to participate in the day-to-day running of the home Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 11 EVIDENCE: Care plans detailed the gender of staff that they wished to support them with their personal care. Service users were aware of their care plan and that they could have access to it when they wanted. Observations and discussions with the relatives, service users and staff confirmed that each individual’s personal care needs had been identified and met. Preferences regarding personal care routines had been recorded. Service users were well dressed and each had their own preferred choice of dress, hairstyle and appearance. Service users said they thought the manager and staff listened to their views, ideas and concerns and that they could discuss these individually with the care staff or the manager. Observations confirmed that staff were attentive and supportive and that positive relationships had been developed with each service user. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 14. Service users were able to maintain and develop their social, emotional, communication and independent living skills. Service users were provided with regular opportunities to engage in appropriate activities, based on their personal preferences. Service users had varied weekly activity programmes and all service users had developed and maintained links with their local community. The daily routines were flexible and promoted individual choice and independence. EVIDENCE: Service users said that staff encouraged and supported them with their chosen activities in the home and in the local community. Three service users were noticeably more positive and outgoing and this appeared to be because of their increased social and leisure activities. All service users said they could choose what they wanted to do and who they wished to spend time with whilst they were at the home. Staff observed were respectful and attentive to the needs of each individual with whom they had obviously developed positive relationships. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. They also said they were able to see visitors in private and that visitors were made welcome, encouraging the maintenance of contact with family and friend, which creates a home that people want to visit. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. Staff had a good understanding of the homes adult protection procedures and timescales involved. They had attended training courses on recognising and dealing with abuse. Service users were aware that they could complain. The homes policies and procedures protected service users from abuse. The manager was aware of the POVA requirements. EVIDENCE: The complaints records confirmed that no serious complaints had been made since the last inspection. Staff had received formal adult protection training. This helps to ensure that service users are protected from abuse. No staff had been referred to POVA. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25 nad 26. All areas of the home seen were clean, homely and comfortable and provided safe access for service users. Effective cleaning routines were in place and the home had the appropriate policies and procedures to ensure the control of infection. The registered providers were keen to ensure that the home was well maintained and could meet service users individual needs. The home is welcoming and attractively decorated and furnished. Locks were not provided to bedroom doors and lockable facilities were not provided in each bedroom. The home did not have enough assisted baths, and the room layout of two bathrooms did not ensure that there is enough room at either side of the baths to enable access for carers and equipment. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 15 EVIDENCE: Service users said that the home was always clean; this they said made them feel safe because the home was well looked after by the staff group. The bedroom doors were not fitted with suitable door locks and lockable facilities were not provided in all the bedrooms. This does not respect the privacy of service users. Lounges and dining rooms were homely and attractively decorated and furnished. Service users could choose to meet with their visitors in these rooms or in the privacy of their own bedroom. Service users could smoke in a designated smoking area. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms provided as required, Staff complained that they could not use two bathrooms, because the baths were of the domestic type and the design of the room made it difficult for those service users with mobility problems to move around in. This does not ensure that the health and welfare of service users and staff is protected at all times. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29. The number and skill mix of the staff employed at the home meets service users needs. Recruitment procedures did not fully protect service users. The home had a training and development plan and all staff had completed a range of training relevant to their role. EVIDENCE: The service users said that there was always enough staff on duty. They added that staff worked very hard and described them as “very caring” “kind” “understanding” and added that staff treated them like human beings they were not intrusive and that you could have a joke with them. Staff files and discussions with the staff and the manager confirmed that all staff had completed detailed induction training. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Staff had completed training on NVQ in care and this had ensured that more than 40 of the staff team were qualified to level 2/3. Staff spoken to confirmed they receive much more than three days paid training, this demonstrates the provider’s commitment to investing in the staff. Staff recruitment files checked were well-ordered and contained most of the required information. New staff were confirmed in post following receipt of two written references, a satisfactory CRB check at the enhanced level and a health declaration. Application forms, interview assessments, job descriptions and codes of conduct had been retained on staff files in addition to full details of induction and additional training. One staff file did have gaps in their CV; this means that the protection of service users could not be ensured. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38. Service users benefited from a home that is well run by the registered manager. The service users and staff said the manager was approachable and very professional. Service users were benefiting from the care given by welltrained staff. The proprietor visits the home on a regular basis but a report was not submitted following his visits. Records were in the main up to date and well organised. The homes policies and procedures met the required standards. A safe environment was not provided in all parts of the home. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 18 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff and service users said that she was committed to ensuring that the home maintains and develops high standards of care, she had completed regular internal audits on all aspects of the service provided by the home. Service users confirmed that they could see the manager when they wished and they said that she was very approachable and supportive. The staff described her as `brilliant`. Records were securely stored as required and those checked were accurate and up to date and in good order. The responsible individual was visiting the home on a regular basis and talking to staff and service users, a report was not written following the visit. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, food safety and infection control. The manager stated that there was a programme for the regular servicing and maintenance of all appliances. No fire exits were blocked. Medication for external use and hazardous substances were noted to be insecurely stored. One member of staff was note to be pushing service users around the home in wheelchairs with not footplates. This does not maintain the service users safety. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 2 x 3 1 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 2 x x 3 3 1 Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 20 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 24 Regulation 16 Requirement All bedroom doors must be fitted with locks suitable for service users capabilities and accessible to staff in emergencies. Gaps in staff’s employment history must be explored. A lockable facility must be provided in each bedroom. Hazradous substances including medication for external use, must be kept in a secure place at all times. Staff must ensure footplates are used on wheelchairs when transporting service users around the home. The room layout of the bathrooms must ensure that there is enough room at either side of baths to enable access for carers and equipment. The domestic baths must be replaced with suitable assisted type baths. A report must be produced following the registered persons monthly visit to the home. N/A Timescale for action 1/12/05 2. 3. 4. 29 24 38 19 16 13 Immediate 1/12/05 Immediate 5. 38 12 Immediate 6. 21 23 1/3/06 7. 8. 33 26 1/12/05 Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 21 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 29 and 31. Good Practice Recommendations 50 of the care staff must be trained to NVQ Level 2 or equivalent by 2005. The manager must have a NVQ Level 4 in management (or equivalent) by 2005. Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westbourne House J55 S21816 Westbourne Hse V247492 130905 UI Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!