Inspection on 19/01/06 for Westbourne House Nursing Home

This inspection was carried out on 19th January 2006.

CSCI 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 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 13/09/05

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 Nursing Home 379a Earl Marshall Road Sheffield South Yorkshire S4 8FA Lead Inspector Janice Griffin Unannounced Inspection 19th January 2006 09:30 X10015.doc Version 1.40 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 Nursing Home DS0000021816.V274448.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 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 Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westbourne House Nursing Home Address 379a Earl Marshall Road Sheffield South Yorkshire S4 8FA 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) 0114 261 0016 0114 261 0020 Palms Row Health Care Limited Mrs Marcella Wilkinson Care Home 71 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (51) of places Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 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 Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 9:30 am to 14:45 pm. As part of the inspection process ten-service users, two relatives and six staff, including the manager on duty, 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, the relatives, the manager and staff for their commitment to the inspection process. What the service does well: What has improved since the last inspection? More care is now taken with the storage of hazardous substances and medication for external use. Staff now ensure that they use footplates on wheelchairs when transporting service users around the home. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 6 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 Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 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 the following standard(s): These standards were not checked they were checked at the last inspection. EVIDENCE: Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 9. Service users told the inspector that they were treated with respect, and the staff respected their privacy and dignity. The inspector observed staff closing doors and speaking with respect when assisting service users. The recording of medication administration charts needs to be improved. EVIDENCE: Records were kept of medication received, and disposed of. One-service users medication recordings showed prescribed medication, which had been discontinued for some time. This could affect the health and well being of service users. A pharmacist had checked the home’s medication systems at regular intervals. The home contracted pharmacist was still disposing of the homes surplus medication. Staff interacted well with the service users, furthermore they were observed closing bedroom, toilet/bathroom doors when attending to service users personal care needs. The service users said this helped to make them feel respected and ‘at home’. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 10 The manager said that service users post was only opened if the service user or their representative requested this. This promotes the privacy of service users. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 15. The service users said the most of the meals provided were in the main wholesome, appealing and well balanced. They said the food served at teatime was repetitive. EVIDENCE: The service users said the food provided at breakfast and lunch was “good and there was always plenty of it”. Three meals were offered each day and snacks and drinks were provided in-between meals. Some service users said that sandwiches and soup were often served at teatime and they were bored with these foods and would like more choice at this meal. The manager had arranged several meeting with the service users to look at reviewing the current menus. This is good practice. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 16 and 17. The homes complaints procedure was clear, accessible and contained all the necessary information. Staff had a good understanding of the procedure and timescales involved. Service users were aware that they could complain. The complaints records were available within the home. The service users legal rights were protected. EVIDENCE: The complaints procedure was available for service users, their relatives and staff. Service users said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They confirmed that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Service user meetings were held regularly and minor issues were discussed, and the appropriate action taken, before the issues had chance to develop into more serious concerns. The manager said that most of the service user had their legal rights protected by advocates, relatives; the court of protection or solicitors. She also said that if any other service users requested access to advocacy services then she would facilitate the service for them, if requested. The homes accounts had been audited. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19,21,23 and 26. The location of the home is suitable for its stated purpose. Service users bedrooms met individual’s needs in a comfortable and homely way. All areas of the home seen were clean, homely and comfortable and provided safe access for service users. EVIDENCE: Effective cleaning routines were in place and the home had the appropriate policies and procedures to ensure the control of infection. The kitchen needs redecorating and the floor covering replacing. 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 Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 14 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. 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. Service users spoken to said that staff were kind and helpful. 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 35 of the staff team were qualified to level 2/3. Several staff said that they had not had any training on caring for service users with dementia. Staff felt they would benefit from this training. Staff spoken to confirmed they receive much more than three days paid training, this demonstrates the provider’s commitment to investing in the staff. New staff were confirmed in post following receipt of two written references, a satisfactory CRB check at the enhanced level and a health declaration. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 15 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 had gaps in their CV; this means that the protection of service users could not be ensured. One qualified staff members file did not detail whether her pin number had been checked out with the NMC. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 16 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,and 35. 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 responsible individual visits the home on a regular basis but a report was not submitted following his visits. The management of service users finances was good. Records were in the main up to date and well organised. The homes policies and procedures met the required standards. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 17 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. She is 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. The finance records of three-service user were checked and receipts were available for all transactions made on behalf of the service user. This protects the service user from financial abuse. 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. Service users confirmed that they could see the manager when they wished and they said that she was very approachable and supportive. Feedback was being sought on a regular basis from service users, their families and other professionals involved with each individual. Records were securely stored as required and those checked were accurate and up to date and in good order. Staff and service users confirmed that they had access to the appropriate records as required. The manager stated that there was a programme for the regular servicing and maintenance of all appliances. No fire exits were blocked and all fire doors were closing on their rebates. A fire officer had recently visited the home and made several requirements that were necessary to improve the fire safety procedures at the home. The manager said that all the requirements had been actioned. Staff were concerned that one service user was regularly gaining access to the outside through one of the fire exits they suggested that the door could be locked with the type of key pad used in other areas of the home. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 18 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 X 1 X 2 X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X X 2 Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 19 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 2 Standard OP9 OP23 Regulation 13 16 Requirement The medication recording charts must only contain details of the service users current medication. All bedroom doors must be fitted with locks suitable for service users capabilities and accessible to staff in emergencies. A lockable facility must be provided in each bedroom. 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. The kitchen needs redecorating and the floor covering replacing. Gaps in staff’s employment history must be explored. Qualified nurses pin numbers must be checked when they commence employment at the home. 50 of the care staff must be trained to NVQ Level 2. The manager must have a NVQ Level 4 in management (or equivalent). DS0000021816.V274448.R01.S.doc Timescale for action 01/02/06 01/06/06 3 4 OP23 OP21 16 23 01/06/06 01/06/06 5 6 OP19 OP29 23 19 01/12/06 01/02/06 7 OP30 18 01/12/06 Westbourne House Nursing Home Version 5.1 Page 20 8 9 OP33 OP38 26 12 A report must be produced following the registered persons visit to the home. A risk assessment must be produced regarding the safety of the fire exist that a service user is getting out of. The fire officer must be consulted before any locking device is fitted to the door. 01/04/06 01/03/06 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 2 Refer to Standard OP9 OP30 Good Practice Recommendations The manager should check to establish if the practice of the contracted pharmacist disposing of the homes old medication is still legal. Staff may benefit from some training on caring for service users with dementia. Westbourne House Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 21 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 Nursing Home DS0000021816.V274448.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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