Inspection on 25/05/07 for Westbourne Lodge

This inspection was carried out on 25th May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westbourne Lodge 09/11/05

Westbourne Lodge 08/04/05

Westbourne Lodge 10/11/04

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 Lodge 126 Cardigan Road Bridlington East Yorkshire YO15 3LR Lead Inspector Mr M A Tomlinson Key Unannounced Inspection 25th May 2007 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 Lodge DS0000061694.V339718.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 Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbourne Lodge Address 126 Cardigan Road Bridlington East Yorkshire YO15 3LR 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) 01262 676611 F/P 01262 676611 Dr Khalid Hussain Javed Dr Mussarat Javed Mrs Sandra Margaret Turvey Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: Westbourne Lodge is a large detached building situated in a residential area of the town. A former dwelling house it has been extended and adapted to provide accommodation for 20 residents. Its location makes it convenient for access to local facilities and amenities and to the town centre. Public transport passes the door. There is a car park. The home is on two floors. Level access is available to all external ground floor doors. There is a passenger lift and chair lifts including one with wheelchair access. The ground floor has communal areas together with a number of bedrooms. The upper floor houses residents bedrooms, all but one with an en-suite facility. Communal bathrooms and toilets are suitably located throughout the premises. There is a large secure garden to the rear provided with suitable outdoor seating. Ramped access is provided to this area. Westbourne Lodge accommodates people admitted by virtue of old age and infirmity, some of whom may be suffering from dementia. The staff provide personal care, an in-house catering service, laundry service and a domestic and cleaning service. Staffing cover is available in the home throughout the 24-hour period each day. Leisure and recreational facilities are provided. Each resident is registered with a general medical practitioner who addresses their primary health care needs and they can access the more specialised health services as required. The current accommodation fees for residents range from £307.80 to £354.30. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit formed an integral part of the annual ‘key inspection’ process for Westbourne Lodge undertaken by the Commission for Social Care Inspection (CSCI). Information contained in this report was obtained through discussions with the home’s registered manager, the staff on duty at the time of the visit and several residents (service users) on a group and individual basis. Telephone discussions were held with the relatives of three of the residents. A discussion was also held with a Diversional Therapist/ Activity Organiser who visits the home on three days each week and the visiting hairdresser. Reliance was also placed on observation of the staff in order to evaluate the support provided for the residents. In addition, the report includes relevant information obtained by the CSCI prior to, and subsequent to, the inspection visit. A number of statutory records kept by the home were also examined and an inspection of the premises carried out. Feedback was provided for the registered manager on the completion of the inspection visit. What the service does well: What has improved since the last inspection? Since the previous inspection in November 2005, the registered manager has made a considerable number of changes for the benefit of the residents. The primary changes or improvements are as follows: • Considerable emphasis has been placed on staff training to ensure that they are competent and confident to provide good standards of care. DS0000061694.V339718.R01.S.doc Version 5.2 Page 6 Westbourne Lodge • The manager has delegated tasks to the staff that are within their remit and ability level. This has provided the staff with a degree of responsibility and accountability for the standard of care provided. Staff supervision and appraisal has been developed so that the staff genuinely feel that they are able to progress in their chosen role. The pre-admission assessment and the care plans have been further refined and developed to make them more meaningful to the staff. The residents’ social care has been improved through the development of a good programme of social activities both within the home and within the community. This has further been enhanced by securing the services of a freelance Diversionary Therapist/ Activity Organiser who is able to provide meaningful activities for all of the residents regardless of disability. The property has been refurbished and decorated to a good standard and now provides the residents with a comfortable and homely place in which to live. • • • • 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. The summary of this inspection report can be made available in other formats on request. Westbourne Lodge DS0000061694.V339718.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 Lodge DS0000061694.V339718.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Prospective residents are provided with a comprehensive pre-admission assessment that enables the registered manager to make a considered decision as to whether the home was suitable for the person and the staff could fully meet their needs. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of three residents were examined. They contained documentary evidence that the resident had been fully assessed prior to their admission into the home. The information obtained by this process enabled the registered manager to make a decision as to whether the home was suitable for the prospective resident and that their needs could be fully met. The assessments were relatively comprehensive and identified the various Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 9 elements of care needs. They also identified a prospective resident’s preferences, abilities and wishes. In this sense they were positive documents on which the resident’s initial care plan could be based. In those assessments examined there was evidence of the involvement of the prospective resident and/or their representative. The home’s assessments had been carried out by the registered manager in the prospective resident’s current accommodation (e.g. home or hospital) if at all possible. Whilst those residents spoken to as part of the care tracking process could not remember their assessment, some of them did recall the registered manager visiting them and asking them questions. The home’s assessment was in addition to any assessment provided by a resident’s placing authority. The registered manger acknowledged that following admission into the home the needs and preferences of a resident would often change due to a change in their environment. This was taken into account by further assessments. When capacity allowed the home had admitted residents on a short-term or respite care basis. These residents had also been fully assessed prior to their admission into the home. Intermediate care was not provided. The registered manager provided evidence that following a decision to admit a prospective resident into the home a confirmatory letter was sent to them and/or their representative assuring them that the home was able to meet their needs. From discussions with the residents, the staff and registered manager, it was apparent that the home had the capacity, and the staff the skills, to meet the assessed needs of the current residents. The care records also contained copies of the terms and conditions of residence that had been signed in agreement by the resident or their representative. The terms and conditions clearly identified the room to be occupied by the resident. Westbourne Lodge DS0000061694.V339718.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The residents’ care plans provided the staff with good quality information to ensure that the residents’ assessed needs were met. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three care records examined all contained a comprehensive care plan for the respective resident. These care plans were in addition to, but compatible with, the care plan provided by the resident’s placing authority if publicly funded. The care plans were subdivided into elements of care need and linked to medium and short-term goals. The plans were holistic in content and in addition to identifying the residents’ physical, social and emotional needs, they also provided relevant information on their abilities, interests and preferences. In this sense the care plans focussed on the positive aspects of a resident not Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 11 solely on their needs. There was written evidence that the residents and/or their representatives had been directly involved in the development of the care plans and had signed the plans in agreement. Whilst those residents spoken to were not familiar with the terms ‘care plan’ or ‘review’ they were, however, aware that records were maintained on them and that staff, particularly their Key Worker, would discuss things with them. It was an expectation that the residents’ Key Worker would spend a minimum of two hours ‘quality time’ each week with their allocated residents on a one-to-one basis. Following these sessions the Key Worker submitted a report that was used by the registered manager to update the respective care plan if necessary. The care plans clearly identified the primary needs of the residents and the actions to be taken by the staff to meet those needs and achieve the agreed goals. The records provided confirmation that the care plans had been regularly reviewed and updated. The reviews directly involved the resident concerned and their representative. The relatives of the residents spoken to confirmed this. In addition to the care plan the care records also included a range of assessments, including those relating to falls, nutrition, pressure sores and general healthcare. These had been regularly reviewed. There was also a personal profile of each resident and an inventory of their personal belongings brought into the home. The records indicated that there were good levels of input from members of the healthcare services and that the residents’ healthcare needs had been promptly addressed. The residents confirmed that were able to see a doctor if they wished and that they had regular visits from a chiropodist and, when necessary, from a practice or district nurse. The nursing notes were readily available in the home. It was apparent from the records and observation of the residents that the staff encouraged them to remain as active as possible. It was noted that the staff did not ‘fuss’ over the residents but allowed them time to move and act at their own pace. The visiting Activity Organiser said that group physical exercises were a part of her routine for the residents. The home continued to use a monitored dosage system for the administration of the residents’ medication. An appropriate policy and procedure was in place. The staff responsible for the administration of medication had been provided with training on the ‘safe handling of medication’ and their competence to carry out the process had been assessed by the deputy manager. All medication was secured in a locked medication room with the key to the room being carried by the senior member of staff on duty. The ‘inuse’ medication was secured in a dedicated drugs trolley which was secured to a wall when not in use. The medication ‘stock’ was secured in a dedicated drugs cabinet. Appropriate arrangements were in place for the administration Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 12 of controlled drugs. Weekly audits of the medication had been undertaken and recorded by the deputy manager. The medication administration records were complete and up to date. ‘Homely’ or non-prescribed medication, such as cough mixtures, had also been recorded. A refrigerator was available for the storage of temperature sensitive medication such as eye drops. From the description of the medication process provided by the deputy manager, it was apparent that it was safe and efficient. None of the residents self-medicated although they all had lockable facilities in their rooms in which they could lock any medication if necessary. From discussions with, and observation of, the residents, it was evident that they were treated with appropriate respect by the staff and spoken to in a mature and friendly manner. The ‘banter’ between the residents and staff was natural and spontaneous. It was evident that the majority of the residents had retained a sense of humour and a zest for life. The residents’ dignity was promoted by having en-suite toilets and their privacy by having the use of locks on their bedroom doors. It was apparent from the inspection of the premises that several of the residents used the door locks. A policy and procedure was available for staff regarding the care of a resident during the final days of their life. It was apparent from discussions with staff that considerable emphasis was placed on ensuring that a resident and their family had good levels of support during this period. Efforts had been made, for example, to ensure that a resident was not left alone but was given good levels of emotional support. The staff provided examples of this. There was recorded evidence that the staff had received training of the subject of dying and bereavement. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The residents are provided with a range of social activities based on their needs, wishes and abilities that help them to live meaningful and reasonably stimulating lives. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a comprehensive programme of social activities that endeavoured to take into account the residents’ abilities and wishes. Whilst many of the activities were undertaken on a group basis the staff stated that they were expected to spend time with the residents on a one-to-one basis. This ‘quality time’ was discussed and arranged with the resident concerned. It consisted, for example, of having an intimate conversation, or doing something specific in the local town. The residents confirmed this. The programme of group social activities covered all days of the week and consisted of one activity in the morning and another in the afternoon. During Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 14 the afternoon of the inspection visit the residents played ‘bingo’ with the assistance of the staff. Approximately twelve of the residents took part and it was evident that they enjoyed it. The home also used the services of a selfemployed activity organiser on three afternoons each week. This person stated that they endeavour to tailor and vary the activities to meet all of the residents’ needs and abilities. The Activity Organiser stated that as in other home’s she visited, there was a core of enthusiastic residents who wished to join in everything, other residents who were more selective and a few who had to be encouraged to join in. She said, however, that the Art and Craft group was the most enthusiastic of any of the homes she visited. Examples of the residents’ achievements from the art and craft group were displayed around the home. The residents were provided with regular opportunities to go out either with staff or their relatives. One resident, for example, was taken to the local supermarket to do their shopping. The Activity Organiser confirmed that there is often ‘loads of cars’ taking the residents out to a concert or theatre. The relatives of the residents confirmed this. One stated, “They (staff) put on entertainment regularly including birthday parties. I can’t fault it”. The residents provided confirmation that they were able to follow their faith and that regular visits were made to the home by members of the local churches. One church in the area, for example, sent volunteers to the home in order to have conversations with the residents which provided them with greater social stimulation as well as contact with members of the local community. In order to maintain their independence the residents were encouraged to do as much as possible for themselves. For example they were encouraged to dress and wash themselves if possible. One very elderly resident confided that she enjoyed whiskey and sherry each day. It was also noted that this resident gave the staff money from her purse when they went shopping on her behalf. The outcome of the programme of social activities and the support of the staff was that the majority of the residents were well stimulated, communicative and presented as having a positive attitude to life. None of the residents spoken to considered boredom to be a problem. Some residents did appear to be rather apathetic and depressed but the records indicated that this had been identified and action taken to endeavour to overcome it. The menus were varied and indicated that the residents were provided with nutritious meals. The choice of meals was a regular agenda item during the residents’ meetings. From discussions with the cook, it was evident that emphasis was placed on the use of fresh meat and vegetables. Care was also taken to ensure that the residents ate fruit regularly. The residents’ likes and dislikes in food were available to the cook. Whilst the residents were provided with hot drinks at set times in the mornings and afternoons, it was observed that the residents were able to have a drink of their choice at anytime. A Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 15 number of the residents had food and drinks in their rooms. Without exception the residents expressed their satisfaction with the quality of the meals. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The residents’ safety and welfare is protected by having good staff support and sound complaints, safeguarding and monitoring procedures. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a suitable complaints procedure in place that was readily accessible to the residents and visitors to the home. Those residents spoken to couldn’t envisage making a complaint but they did confirm that they had the opportunity to speak with the staff or the manager with regard to any concerns or worries they may have. The registered manager placed importance on the openness and transparency of communication within the home. There was evidence, for example, that the residents and their families were kept informed of what was going on in the home and had the opportunity to make their views known. Regular staff meetings assisted in this. The relatives of residents spoken to confirmed that they kept well informed as to the welfare of the resident concerned and expressed their confidence that they could talk to the registered manager about any concerns. Management were also available at weekends to discuss any issues. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 17 The Key Worker system also provided protection for the residents insofar as they had the opportunity to discuss personal concerns with the residents allocated to them. The staff spoken to were aware of the Whistle Blowing policy and procedure and felt confident that they would use it. An Adult Protection or Safeguarding policy and procedure were in place. These incorporated the guidance provided by the local authority. The staff confirmed that they had received training on the subject of adult protection including identifying the types and indications of abuse. During the past year a complaint had been made by a relative of a resident alleging poor standards of care. This had been fully investigated by the local social services and the primary allegation was not substantiated. There were, however, elements of care that could have been handled better. This had been acknowledged by the registered manager in a letter to the complainant and the issue discussed in a staff meeting. In summary, the registered manager handled the allegation in a professional and competent manner. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 The home presents as being a pleasant and homely environment in which the residents’ are able to live reasonably active lifestyles at their own pace. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection a considerable number of improvement had been made to the premises. For example, it had been redecorated and furnished to a high standard and additional equipment had been purchased to assist those residents who had mobility problems. The premises continued to be maintained to a good standard and a recorded programme of maintenance was available. All parts of the property were clean Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 19 and hygienic. The domestic confirmed that he had a rigorous programme of cleaning to ensure that the high standards were maintained. As far as could be ascertained from the records, the home satisfied the specific requirements of the Fire and Environmental Health departments. The home had a main lounge, which was also used for group activities, a dining room and a sitting area. These were of an open-plan design and consequently there was only limited privacy provided by these areas. This was raised by a relative of a resident who said that the alternative was to go to the resident’s bedroom for greater privacy but the effort for the resident in going upstairs was rather off-putting. The communal areas were furnished to a good standard and met the needs of the residents. The natural and artificial lighting was adequate throughout the property thereby enabling the residents to see and read in comfort. The home was a smoke-free environment with staff who smoked having to do so outside of the building. The property had a secluded garden that had seating for the residents. The car park at the front of the property provided parking spaces for several vehicles. The home did not have a staff room and consequently the staff tended to take their breaks along with the residents. The staff hand-over between shifts was held in the dining room. Care was taken by the staff to ensure that the confidentiality of the information discussed was maintained. All of the residents’ rooms except one had an en-suite toilet and wash-hand basin. In the one exception the occupant of the room had a sole access to an adjacent toilet. The en-suite facilities helped promote the residents’ dignity and privacy. There were adequate numbers of baths and showers in order to provide reasonable choice for the residents. All of the bedroom doors had appropriate locks fitted which again enhanced the residents’ level of privacy. Only a few residents had chosen to lock their bedroom doors during the day. The residents had furnished their rooms with their personal belongings thereby maintaining their links with past. The bedrooms inspected were furnished and decorated to a good standard. Several of the residents had chosen to use their own furniture. All of the bedrooms were clearly identified through the use of the respective resident’s photograph and name on the bedroom door. Of the two shared bedrooms, a married couple occupied one and the other by two residents whose families had agreed would benefit from sharing. The shared bedrooms had privacy screening available. The hot water accessible to the residents had thermostatic valves fitted thereby preventing scalding by limiting the water to a safe temperature. The temperature of the hot water had been regularly recorded to confirm that the valves were operating properly within set limits. The home had adequate laundry facilities. The staff and the more able residents confirmed that the residents were provided with clean clothing each Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 20 day. A relative of a resident commented that the resident concerned had worn the same clothing on consecutive days over the weekend. The registered manager acknowledged that this was possible as the clothes may have been laundered on a Saturday and therefore available on the Sunday. In order to minimise a possibly poor impression being given by this, the manager was endeavouring to ensure that the same clothing is not worn by a resident on two days in a row. As previously stated the cleanliness of the home was of a high standard with all of the rooms being cleaned daily. Even though many of the residents had numerous ornaments in their rooms, these were all dust free. It was apparent that the bed and furniture in each room was moved each week so that the floor could be cleaned underneath. The en-suite facilities were clean and hygienic. The home had a basic sluice available although this was, according to the staff, rarely used. Whilst the majority of the residents had problems of incontinence, there was no physical evidence of this. To the visitor the home presented as being a pleasant and homely environment in which the residents’ were able to live reasonably active lifestyles at their own pace. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The residents are safeguarded by the use of robust staff recruitment and selection procedures. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing level continued to satisfy that recommended by the Staffing Forum. In general there were three care staff on during the day, two in the evenings and two waking staff at night. According to the staff roster this staffing level also applied at weekends so that the same level of care could be provided. A senior member of staff was also on duty at weekends. In addition to the care staff the registered manager, administrator, catering and domestic staff were also on duty on the day of the inspection visit. It was evident from observing the staff that not only did they have an excellent relationship with the residents but that they also worked as a team and supported each other. The staff held common aims regardless of role which were primarily for the well being of the residents. One member of staff stated, “We encourage the residents to do as much as possible for themselves and several have made real progress”. The care records confirmed this comment. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 22 The staff records indicated that all of the care staff either had, or were in the process of achieving, a National Vocational Qualification at level 2 or above. It was apparent from discussions with the staff that they were well motivated and several said that they had plans to progress to a senior position within the home. The registered manager supported this and said that they encouraged staff to progress even if it meant them finding alternative employment. The staff were provided with a good programme of training. This not only covered mandatory subjects such as first aid, health and safety and fire procedures but also included professional subjects such as dementia and bereavement care. Staff training was fully recorded. The staff presented as being enthusiastic regarding training and confident that they were providing good standards of care. A staff hand-over between shifts was observed. The deputy manager chaired this. It was comprehensive in content and covered all of the residents’ needs, moods and any special support required. The staff records confirmed that a robust staff recruitment process was being followed. This consisted of prospective staff submitting a formal application, undergoing an interview and being fully vetted that included a CRB check. According to the registered manager there had been occasional exceptional circumstances when it had been considered necessary to start a new member of staff before the completion of the CRB check. In these situations the member of staff had undergone a POVA First check and appropriate supervisory arrangements had been put in place until the full vetting process had been completed. The recruitment process ensured that the residents would not be put at risk from unsuitable staff. The staff confirmed that they had been provided with contracts and terms and conditions of employment. Evidence was available to confirm that they had been introduced to the code of conduct set by the General Social Care Council. All of the residents spoken to commended the support and care provided by the staff. A visitor to the home stated, “I think that this is a good home. It’s always very friendly and the residents always appear happy. Being a small place they get personal attention”. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 The staff are supported by a competent and well qualified registered manager who enables them to provide the residents with good standards of care. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was qualified to the required standard. In addition to this she had undertaken other and more specific management courses. Since taking over the home as registered manager she had made considerable changes primarily for the benefit of the residents. These changes included a Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 24 greater degree of delegation to the staff. This had provided the staff with increased levels of responsibility and accountability. She had also encouraged the staff to have a greater say in the operation of the home through the introduction of a Key Worker system, staff supervision and appraisal and by holding meaningful staff meetings. These changes were reflected in the records. The staff said that the registered manager provided them with excellent support. They felt confident that they could discuss any issues with her and that action would be quickly taken to resolve the issue. They said that she welcomed new ideas providing that they were genuinely for the benefit of the residents. The registered manager presented as having a democratic style of management which was underpinned by a good standard of professionalism thereby creating a pleasant working environment. By this approach the registered manager had established an open, positive and inclusive atmosphere in which the staff felt a degree of ownership over their actions. The registered manager had obtained a formal Quality Assurance system that enabled her to assess the quality of the service and take action to address identified weaknesses. The process included actively obtaining the views and opinions of the residents and visitors to the home. Audits were also undertaken on all the various elements of the service such as care, catering activities etc. to verify that the home was meeting its planned goals. The registered manager saw the residents and staff meetings as well as any complaints as part of the quality assurance process. The home had achieved the Investors in People Award and had been registered with the local authority’s quality development system (QDS Part 1 and 2). The home had a policy of non-involvement in the residents’ financial affairs. The residents or their representatives were encouraged to retain this responsibility. As previously mentioned in this report, it was observed that the residents were able to pay themselves for any purchase that they had requested the staff to make on their behalf. A monthly invoice was provided by the home for the payment of some services such as chiropody and hairdressing. The home’s administrator had the responsibility for maintaining the home’s financial records. She was in the process of taking a National Vocational Qualification at level 3 in Administration. The home’s records were readily available and were maintained in a chronological and systematic manner. Several statutory records were examined including the accident, fire safety, medication and health and safety records. These were all up to date. From an examination of the health and safety records and the inspection of the premises, it was evident that Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 25 appropriate action had been taken to ensure that the premises were safe for use by the residents and staff. Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 26 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 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 4 X 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 3 Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations In order to provide greater flexibility for the residents to make maximum use of the community facilities, consideration should be given to providing the home with specialist transport that can transport people who have mobility problems or use wheelchairs. The day staffing levels should be kept under review to ensure that they remain appropriate to meet the changing needs of the residents. 2. OP27 Westbourne Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lodge DS0000061694.V339718.R01.S.doc Version 5.2 Page 29 - 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. 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