Inspection on 24/10/06 for Westbourne House Nursing Home

This inspection was carried out on 24th October 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 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 19/01/06

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 Key Unannounced Inspection 24th October 2006 09:00 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.V308692.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V308692.R01.S.doc Version 5.2 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 none www.palmsrow.co.uk 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.V308692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 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. Copies of the last Commission For Social Care inspection reports were available for service users and their families to read. The weekly fees range from: £303 to £483. This information was provided on the 25th October 2006. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 09:00am to 15:20 pm. As part of the inspection process the inspector spoke to, eight service users, five relatives, four staff and the manager. The inspector would like to thank the service users, the relatives, the staff and the manager for their openness and for their commitment to the inspection process. The inspector was pleased to note that all the service users and relatives spoke highly of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the manager and staff who were approachable, supportive and appeared sensitive to the needs and feelings of the service users. The relatives described the service as excellent. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Since the last inspection no complaints have been received about this home. The home has a system for displaying information and bringing attention to community events and activities. Feedback on the inspection was given to the manager. What the service does well: All the service users and relatives said the service users were well cared for by the staff. They described the staff as being “excellent” and very hard working. Service users were able to visit the home for trial periods. The staff said that the manager considers carefully the needs assessment for each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Clear information about contracts/terms and conditions, fees and extra charges were available in a format appropriate to each individual service user and their families. 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. Feedback was being sought on a regular basis from service users and their families. Staff interacted well with each service user and it was obvious from discussions with them and the relatives that staff had developed positive relationships with them. The cook was familiar with the dietary needs of service users. The inspector observed the lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Documentation and discussion with four staff showed that they have had Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 6 training in the specialist area of work that they work in. Records were in the main well ordered securely stored and up to date, the manager was keen to ensure that any issues found were addressed. 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 Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 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.V308692.R01.S.doc Version 5.2 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): 2, 3 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with eight service users, five relatives, four staff, the manager and a visit to the home. No service users have moved into the home without having his or her needs assessed, this ensures that care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. Relatives confirmed that this helped service users to get to know everyone at the home, which made them feel less anxious. Intermediate care is not provided at this home. EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. Service users and the relatives spoken to said at the time of the service users admission they were able to have informal introductory visits to the home and they had been provided with a contract containing the relevant information. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 9 Records checked and discussion with eight service users and five relatives confirmed that service users families had been 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 Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with eight service users, five relatives, four staff and a visit to the home. Service users were encouraged and supported by staff to make decisions. This protects the rights and well being of service users. Information in care plans was good; it gave the staff full knowledge of the service users physical, social, health care, religious and cultural needs. Risk assessments had been reviewed on a regular basis. This protects the service users from harm. There was evidence in the care plans to show that the service users families are involved with the care planning production and the review. This allows the families to have a say in how their relatives care needs will be met. The local pharmacist is disposing of the homes medication; the manager was not sure whether the pharmacist holds a Waste Management Licence. This is not safe practice. EVIDENCE: Staff were observed knocking on bedroom doors and they waited to be invited in before entering. Three service users plans of care were checked. Each set out individual service users needs and the action required and taken by staff to Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 11 ensure those needs were met. Discussion with four staff identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users weight was being checked on a regular basis. A range of aids to assist service users with mobility problems was provided; these included lifting hoists, walking frames and wheelchairs. The risk assessments in care plans had been reviewed on regular basis. The care plans detailed the gender of staff that the service users wished to support them with their personal care; they also contained details of the service users religious and cultural needs. Service users and their relatives have been involved with production of the care plans and the reviews. Systems were in place to ensure the safe storage, recording and administration of medication. Records were kept of medication received, and disposed of. The local pharmacist is disposing of the homes medication; the manager was not sure whether the pharmacists holds a Waste Management Licence. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with eight service users, five relatives, four staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. Service users were supported with maintaining and developing contact with their family and friends, and relatives said that they were always welcome at the home. Which creates a home that people want to visit. A good choice of food was offered to service users at lunchtime. Eight service users were being offered special diets on a regular basis. This promotes the rights of service users. EVIDENCE: Service users and relatives confirmed that staff were extremely supportive and always encouraged the service users to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. The cook was familiar with the dietary needs of service users. The inspector Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 13 observed lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Eight service users were receiving special diets. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 14 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 18. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with eight service users five relatives, four staff and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This protects the rights of service users. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for visitor, relatives and staff. Service users and relatives spoken to 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 also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last inspection no complaints have been made about this home. The staff had received training on recognising and dealing with abuse. Staff had been made aware of the action to take in dealing with third party information. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is: good. This judgement has been made after discussion with eight service users, four relatives and using available evidence including a visit to the home. On the day of the inspection the home was clean and well decorated. This made the home look well cared for. The bedroom doors were fitted with locks. This promotes the privacy of service users. The home does not have enough assisted baths. This is not adequate for the service users with disabilities. The string light cords in some toilets were dirty and some easy chairs damaged. This does not protect the health and wellbeing of service users. EVIDENCE: The rooms were well decorated and the fixtures and fittings of a good standard, it is well maintained and adapted to meet the needs and wishes of the service users. Service users and relatives said that the home was always clean. Bedroom doors were fitted with suitable door locks and lockable facilities were provided in all the bedrooms. The string light cords in some toilets were Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 16 dirty and some easy chairs damaged. The appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities and a good supply of equipment was also available for those service users. 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. The home had a proactive infection control policy and they work closely with external specialists, e.g. the Health Authority, Environmental Health and their own staff to ensure infections are minimised. Clinical waste is properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30. Quality in this outcome area is: good. This judgement has been made after discussion with eight service users, five relatives, four staff and using available evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The homes recruitment procedures were not adequate, as they did not protect the service users from harm. The home had a training and development plan and all staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. 26 of the staff was trained to NVQ level 2. EVIDENCE: The service users and relatives said that there was always enough staff on duty. They said that the staff worked very hard and described them as “very caring, kind and understanding”. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Three staff files were checked; the files demonstrated that the recruitment processes did not meet the standard as required by the Care Homes Regulations. Criminal record checks had been done for all three staff. Two references had been obtained. Gaps were noted in one staff’s employment history. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with four staff Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 18 and the manager confirmed that all staff had completed detailed induction training. 26 of the staff team were qualified to NVQ level 2. Staff were being formally supervised at the frequency required to fully ensure individual staff development and the monitoring of care practices Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 19 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, 35 and 38. Quality in this outcome area is: good. This judgement has been made after discussion with eight service users, four relatives and using available evidence including a visit to the home. The service users, relatives and five staff spoken to said the manager was approachable and very professional. Service users and relative’s surveys are completed annually, which ensures that the home is run in the best interest of service users. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. A safe environment was not provided in all parts of the home. This does not protect the health and welfare of the service users. EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff said she was committed Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 20 to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. She has completed her NVQ level 4 training. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. There was a quality assurance system, which sought the views of service users and relatives. The manager said that the responsible individual visit the home on a regular basis a report is written following the visits. No fire exits were blocked but one fire door was not fully closing on its rebate and hazardous substances were noted to be insecurely stored. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnessed all transactions. The accounts are audited annually. All records were available for inspection up to date and securely stored. Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13 Requirement The manager must check to establish if the pharmacy disposing of the waste medication holds a Waste Management Licence. The damaged easy chairs must be repaired or replaced. 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. This requirement has been outstanding since 01/06/06. The dirty string light cords must be cleaned or replaced. Gaps in staff’s employment history must be explored. 50 of the care staff must be trained to NVQ Level 2. Fire doors must fully close on their rebates. Hazardous substances must be kept in a secure place at all times. Timescale for action 01/12/06 2. 3. OP19 OP21 23 23 01/02/07 01/03/07 4. 5. 6. 7. 8. OP26 OP29 OP30 OP38 OP38 12 19 18 23 12 01/01/07 01/02/07 01/12/06 25/10/06 25/10/06 Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 23 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 OP9 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. 2. OP30 Westbourne House Nursing Home DS0000021816.V308692.R01.S.doc Version 5.2 Page 24 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.V308692.R01.S.doc Version 5.2 Page 25 - 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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