Inspection on 08/04/05 for Westbourne Lodge

This inspection was carried out on 8th April 2005.

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

The inspector 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 25/05/07

Westbourne Lodge 09/11/05

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 David Blackburn Unannounced 8 April 2005 9.30 a.m. The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbourne Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Westbourne Lodge Address 126 Cardigan Road, Bridlington YO15 3LR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01262 676611 01262 676611 sandieturvey@yahoo.co.uk Dr K H Javed and Dr M 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 10/11/04 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 service users. 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 service users’ 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 inhouse 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 offered by the staff in-house. Each service user is registered with a general medical practitioner who addresses their primary health care needs and can access the more specialised health services as required. Westbourne Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection on which this report is based was the first to be carried out in the inspection year April 2005 to March 2006. It was undertaken over 8.5 hours including preparation time. The focus was on a number of the key standards together with those subject to requirements or recommendations at the last inspection. An inspection of some of the premises, including a number of bedrooms, was carried out. A number of records were also examined. Discussions were held with the home owners, manager, five staff including carers, the cook and a domestic, eight service users, three relatives and one visiting health care professional. What the service does well: What has improved since the last inspection? What they could do better: While a good pre-admission assessment form was used, this should be signed and dated by the staff member making the assessment. The owners of the home and their manager should continue to encourage care staff to undertake and achieve a National Vocational Qualification in care. Please contact the provider for advice of actions taken in response to this Westbourne Lodge Version 1.10 Page 6 inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne Lodge Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westbourne Lodge Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6. Information published by the home together with a detailed pre-admission assessment procedure was very good providing users and prospective users of the service with a clear indication of the care, services and facilities on offer in the home and assuring them that their needs would be met. EVIDENCE: The new fully revised and updated Statement of Purpose and Service User Guide met current requirements. Both documents were clear, precise, informative and detailed in their content. Good use was made of colour and a large print font was used. They were displayed in the main entrance hall of the home. Some visitors made reference to these documents describing them as “useful and informative”. Pre-admission assessment forms were supported by an assessment and initial care plan from the placing or funding authority where applicable. The information on file was comprehensive and detailed. It gave a good indication of the care needs of the prospective user of the service. It was recommended that they be signed and dated. The registered providers stated they offered no form of intermediate care. Westbourne Lodge Version 1.10 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 standard(s) 7, 8 and 9. The physical and health care needs of service users including medication were well recorded and acted upon by staff promoting good health. EVIDENCE: Each of the five case files examined, including the one of the last service user admitted, contained an informative and detailed care plan. Risk assessments covering a number of aspects of daily living were also available. Care plans had been subject to monthly review by staff and bi-annual review by the placing or funding authority. The health care needs of service users were recorded on their individual care plans. Referrals to outside health agencies were detailed. Nutritional screening, pressure area and tissue viability care were recorded where necessary. A visiting health care professional was complimentary towards the manager and staff. Staff were said to be “pro-active rather than reactive” with a realisation that “prevention was better than cure.” They were knowledgeable about their users of the service, “there’s always someone who is aware of what has happened and why I have been called.” Calls for attendance were appropriate and staff listened to and acted upon the advice given. One service user had nutritional, dietary and specific health care needs. These were recorded and the visits of the professionals providing the service were also noted. The particular service user said she was “very pleased with the service Westbourne Lodge Version 1.10 Page 10 she received in the home.” She confirmed that the district nurse and dietician visited. Proper procedures were in place for the ordering, receipt, storage, administration, recording and return of medication and were being followed. Seven staff who currently administer medication have achieved the Certificate in Safe Handling of Medicines. Confirmatory letters were seen. A number of other staff were currently undertaking this course. Westbourne Lodge Version 1.10 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 standard(s) 13 and 15. Visiting arrangements were flexible allowing service users to maintain good and regular contact with family and friends. The dietary needs of service users were well met with a varied menu of food being offered that satisfied service users tastes and choices. EVIDENCE: Visiting arrangements were clearly shown in the literature available on the home. Visitors said no restrictions were placed upon them. They were free to visit at any reasonable time. They were offered suitable refreshments. A new menu, devised by the registered manager and cook in conjunction with service users, was being introduced. Choice was available at all meals. Service users confirmed that alternatives were readily available. Observation of one mealtime showed this to be the case. Food was properly served with attention given to presentation. Tables were appropriately set. Service users said they well pleased with the food on offer. “I eat everything. It’s all good.” “If I don’t like something, I can choose something else. It’s no problem.” Visitors made similar comments. “Since the new cook was appointed mum has said the food has been even better.” The minutes of the Residents’ Meeting recorded favourable comments about the food. Apart from breakfast, mealtimes were set. None of the service users expressed any concerns about this. Special diets and food needs can be readily and easily met. Westbourne Lodge Version 1.10 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 standard(s) 16 and 18. The production and display of a relevant complaints procedure and staff’s good knowledge of adult protection issues safeguarded service users from abuse. EVIDENCE: A revised complaints procedure was in place. This met current requirements. It was on display in the entrance hall. A complaint recording form was also available. Service users said they were aware of how to raise any concerns. Visitors said they would speak with the registered providers or registered manager in the first instance. Comprehensive policies and procedures on the protection of vulnerable adults were seen including the multi-agency agreement. The registered manager had undertaken a course on adult abuse awareness. The certificate of attendance was seen. She had cascaded this training and information to staff. This was confirmed by a number of the care staff. In discussion they all appeared confident in the action to be taken should abuse be suspected or alleged. A revised whistle blowing policy and procedure was seen. Staff confirmed they had received a copy. The registered providers have produced a clear statement and policy about their and their staff’s non-involvement in any service user’s financial affairs. One service user said her family took responsibility for her affairs. Westbourne Lodge Version 1.10 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 standard(s) 19 and 26. Recent investment had improved the appearance of this home creating a comfortable and safe environment for those living there and those visiting. EVIDENCE: The premises appeared to be in good structural and decorative order. Improvements were being made to the grounds. Of the 18 bedrooms two were occupied on a shared basis. All but one single room had an en-suite facility. There was a passenger lift and two stair lifts, one with wheelchair capacity. Ramped access was available to all external doors. New bed linen, tableware, crockery and cutlery had been purchased. Very favourable comments were received from service users and visitors about the improvements being made, “ at last the cups match the saucers.” The last reports from the Fire Officer and the Environmental Health Officer were examined. Any requirements had been addressed and resolved. Those parts of the premises seen were warm, clean and free from offensive odours. The appointment of staff specifically for domestic duties had contributed to the overall improvement. Appropriate arrangements had been made for the laundering of bedding, linen and personal clothing. Hot water temperatures were properly regulated. Westbourne Lodge Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. Good progress has been made in addressing the staffing issues within the home and as a result service users were assured their continuing care, dietary and domestic needs received an improving service. EVIDENCE: Since the last inspection specific catering and domestic staff had been employed. Care staff hours had been increased. This had resulted in care staff being able to devote more time to the meeting of service users’ personal care needs. Service users and visitors applauded these changes, “ care staff can now give more attention to my mum.” “The staff do seem to have more time now.” Records showed staff came from different backgrounds and with varying life experiences and skills. Staff said “morale was good.” 14 care staff are employed. Of these five had a National Vocational Qualification (NVQ) in care to at least level 2. Five others were said to be working towards the award. Staff confirmed they had achieved this qualification or were continuing with their work towards it. The registered providers and registered manager were aware of the need for at least 50 of the care staff to have achieved a NVQ in care to level 2 by 2005. Westbourne Lodge Version 1.10 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 and 38. The home was well managed. Systems were in place for consultation with service users and visitors with clear evidence that the views and opinions received were acted upon. Proper attention was given to health and safety promoting a safe and secure environment in which service users could live. EVIDENCE: The registered manager was well experienced with over 20 years in the care sector. She was qualified to run and manage a care home having achieved a national Vocational Qualification in care and management to level 4. Service users, visitors and staff spoke in complimentary terms about her abilities and capabilities. All said she “was approachable, knowledgeable and adopted a hands-on approach.” The registered providers had undertaken a survey of service users, relatives, visiting professionals and other stakeholders. The summary report of results, outcomes, analysis and subsequent plan of action for the necessary improvements were seen. The requirements and recommendations made at the last inspection have been addressed and resolved. A Residents’ Meeting Westbourne Lodge Version 1.10 Page 16 was held quarterly and enjoyed a good attendance. Comments were read in the minutes about service users’ satisfaction with the improvements in staffing, activities and equipment. Proper regard was being given to the promotion and maintenance of a safe and secure environment for service users, visitors and staff. A number of satisfactory safety reports and certificates were seen relating to the premises. Westbourne Lodge Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 3 Westbourne Lodge Version 1.10 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation NONE 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. 2. Refer to Standard 3 28 Good Practice Recommendations The pre-admission assessment forms should be signed and dated by the person completing them. The registered providers are reminded of the need for 50 of the care staff to have achieved a National Vocational Qualification in care to at least level 2 by 2005. Westbourne Lodge Version 1.10 Page 19 Commission for Social Care Inspection Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Lodge Version 1.10 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!