Inspection on 09/11/05 for Westbourne Lodge

This inspection was carried out on 9th November 2005.

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

The inspector 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 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 David Blackburn Unannounced Inspection 9th November 2005 10:15 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.V264925.R01.S.doc Version 5.0 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.V264925.R01.S.doc Version 5.0 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 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.V264925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th April 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 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 DS0000061694.V264925.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be carried out in the inspection year April 2005 to March 2006. It was carried out over four hours including preparation time. The focus was on those key standards not assessed at the first inspection in April 2005 together with those that were the subject of a requirement or recommendation. An inspection of some parts of the premises including a small number of bedrooms was undertaken. Documents including policies and procedures were examined. Discussions were held with the registered manager, care and ancillary staff. A number of residents were spoken with and their comments are included in this report. An analysis of a recent survey of residents, relatives and visiting professionals was seen. Relevant comments from this survey are also included. What the service does well: Residents could be assured their needs and choices would be known prior to admission through the good assessment procedures in place. Residents cold be assured their needs would be met through the good care planning and recording systems in the home. A visiting professional said “Residents always appear well cared for. I am very impressed with the standards of care in the home.” Residents could be confident their concerns and complaints would be listened to and acted upon through a good and robust complaints procedure. Residents were able to live in a clean, comfortable and secure environment. A visitor said “It’s always very friendly and a pleasure to visit.” Residents were cared for by a competent, well-trained and highly motivated staff team. They ensured that the care and services on offer were given in the most appropriate manner. A visiting professional said “Staff are friendly, helpful and professional.” The home was well managed with attention given to the feedback from residents on the home’s overall performance. A comment was made that “the manager has always been approachable.” Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 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.V264925.R01.S.doc Version 5.0 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): 3. Residents were assured their needs and choices would be fully and properly assessed prior to admission. EVIDENCE: The case files of the last two residents to be admitted were seen. They contained an assessment of needs under a number of relevant headings. Some assessments had been carried out by the care manager from a placing or funding authority. Other residents, privately funded, had been assessed using the home’s assessment form. Visits to the prospective resident’s present location had also been undertaken wherever possible. All assessments had been signed and dated. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. The clear and consistent care planning system provided staff with the information needed to properly meet residents’ needs. Personal support was offered in a way that promoted and maintained residents’ privacy and dignity. EVIDENCE: A number of care files and care plans were seen. All were maintained in a proper manner that enabled ease of use and retrieval of information. They were comprehensive in the detail recorded. This provided staff with the information needed to meet the individual resident’s needs. Care plans were regularly reviewed and signed by the resident or their representative. Personal care was offered in the privacy of the bedroom or bathroom. Both situations had suitable privacy locks. Care plans detailed how care was to be given, when and by whom. The registered providers had produced a number of policies and procedures that were unequivocal in describing how care was to be offered. Residents were satisfied with the care being offered and paid compliments to the staff. They commented that care was offered in an appropriate way according to their particular preferences. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 10 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 and 14. Residents’ use of in-house and external facilities and amenities were promoted and maintained enabling them to have a number of different life experiences. EVIDENCE: A diversional therapist had been appointed for two days each week. This person had extended the variety of activities and pastimes in the home. Residents expressed their total satisfaction with the activities on offer in the home and at external locations. Staff made every effort to ensure residents were able to undertake leisure and pastime activities on a communal and individual basis. Activities included group trips to the theatre, individual shopping excursions, group events in the home including a bonfire party and personal preferences such as reading or watching television. The registered providers had a policy of non-involvement in residents’ personal affairs. Residents were expected to deal with their own personal affairs or appoint someone on their behalf, for example a relative. Residents were encouraged to provide personal items to decorate and display in their rooms including small items of furniture, photographs and pictures. All items brought into the home were recorded in the individual’s case file. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 11 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. Residents were assured their complaints and concerns were listened to and acted upon. EVIDENCE: A clear and detailed complaints procedure was in place. A copy was displayed in the entrance hall. The procedure showed how to complain, to whom and gave timescales for any written response. Details of the regulatory authority were given including any complainant’s right to approach them directly. A complaint record form was also available. There had been one complaint since the last inspection. This had been substantiated. The details of the complaint, correspondence, outcomes and actions taken were recorded and seen. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 12 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 and 26. Environmental standards were very good providing residents with an attractive and homely place in which to live. EVIDENCE: Overall the premises remained in a good condition internally and externally. Improvements continued to be made. Externally, the car park had been resurfaced and the garden landscaped. Internally, the wooden entrance floor had been cleaned and new lifting equipment had been purchased. New bedding had been provided. Redecoration, refurbishment and re-carpeting were undertaken as and when necessary. A small number of bedrooms were seen together with some communal areas. All were clean, warm, tidy and odour free. The appointment of domestic staff had made a significant contribution to the overall good standard noted in those areas seen. Residents were complimentary about the overall standards. Proper systems were in place for the laundering of bedding, linen, towels and personal clothing. Proper attention was given to infection control. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 13 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): 28, 29 and 30. Residents’ quality of life was supported by a motivated, well-trained and committed staff team. Good recruitment procedures ensured residents were protected from harm. EVIDENCE: The staff comprised the registered manager, a deputy manager, 13 care assistants, catering and domestic staff. Of the care staff three had gained a National Vocational Qualification to level 3 and four to level 2 thus achieving the required 50 . Four other staff were working towards this award. A recruitment and selection policy was seen. The files of the last two staff to be appointed were examined. The files contained a job description, application form, written references, enhanced disclosures from the Criminal Records Bureau and a copy of the terms and conditions of employment. A new job description was being introduced that clearly showed the tasks to be undertaken and the standards to be reached. The files seen also contained details of the induction and foundation training (to TOPSS standards) together with the relevant certificates. All staff had received a copy of the General Social Care Council’s Code of Conduct. A training and development plan for 2005 to 2006 was seen. Staff were well motivated and committed to training. They spoke of a variety of courses that they had attended including medication, infection control and depression. All Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 14 staff had attended courses relevant to their position and work in the home. Other courses were planned for the future including dementia care and diabetic care. These courses had been arranged as residents had recently been admitted with these conditions. The registered manager was undertaking further management training and three care staff were involved in work towards the Diploma in Management (Health and Social Care). Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 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 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): 33, 35 and 38. The systems for consultation were good with evidence that indicated residents’ views were both sought and acted upon. EVIDENCE: A recent survey had been carried out using a written questionnaire distributed to residents, relatives and visiting professionals. A copy of the analysis of responses was seen. The overwhelming majority of comments were very positive. The registered providers had introduced a policy of non-involvement in residents’ affairs. No money was held on behalf of any resident. It was said that a watch had been deposited in the safe following the admission of a resident to hospital. There was no written record of this transaction. It is important that a record is maintained of all items deposited with the manager for safe keeping and of their return. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 16 Proper attention was being given to matters of health and safety. Staff were well aware of their responsibilities to maintain a safe, secure and hazard free environment. A number of safety certificates and reports were seen. All were up-to-date and relevant. Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 1 X X 3 Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 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 OP35 Regulation 16(2)(l) Requirement A record must be kept of any valuables deposited for safe keeping in the home and of their return. Timescale for action 18/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westbourne Lodge DS0000061694.V264925.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office 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 DS0000061694.V264925.R01.S.doc Version 5.0 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. 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