Inspection on 01/09/05 for Westbridge House

This inspection was carried out on 1st September 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

Westbridge House 17/10/08

Westbridge House 20/10/06

Westbridge House 22/02/06

Westbridge House 22/11/04

Westbridge House 25/05/04

Westbridge House 01/03/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Westbridge House 1 Westfield Road Barton on Humber North Lincs DN18 5AA Lead Inspector Stephen Robertshaw Unannounced 1 September 2005 st 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westbridge House Address 1 Westfield Road Barton on Humber North Lincs DN18 5AA 01652 632427 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) Mr Kumar Thakerar Sandra Cox Care Home 22 Category(ies) of MD (22) registration, with number of places Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions to the homes registration. Date of last inspection 22/11/04 Brief Description of the Service: Westbridge House is registered for 22 service users in the category of mental disorder The accommodation is over four levels, and would not be appropriate for individuals using wheelchairs The kitchen has recently been refurbished, and a new dining room/conservatory unit has been included. The home does not provide nursing care, but it works closely with the community health teams especially the community mental health team, to meet the specific needs of individual service users The top floor of the home continues to used by the company’s home care services, and the staff and visitors to this service have to access the homes service users areas gain access the stairs to their offices. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 1st September 2005 and it was unannounced. The inspection was over a period of 8hrs, and the inspector gained the evidence for this report through observing records in the home, observations of the staff interacting with the service users, discussions with service users, interviews with staff and management and a tour of the environment. Most of the required standards were met and there were no major concerns identified during the inspection. What the service does well: The home provided clear information to prospective service users and their families of the services that are available at the home. The service users stated that the staff were very helpful and supportive. Westbridge House staff receive regular training to make sure that they can meet the needs of the service users. The home maintains good contact with outside professionals to ensure that the healthcare needs of the service users are met. The environment is maintained clean and free of any bad smells. Individual service users rooms had been personalised to their own tastes. Before new service users are admitted in to the home their needs are assessed to make sure the home is the right placement for them. The assessments are a combination of the homes pre-admission information and care management assessments. The home is located close to the centre of the village and the service users stated to the inspector that they access the local services on a regular basis. This includes socially, shopping or attending voluntary work or education classes. Service user, visitors to the home and interviews with the staff confirmed that the management if the home was open and easy to access. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 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. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 and 3 The home gives the service users the opportunity to visit the home before they move in and assesses their individual needs to make sure that they can be met at the home, and to make sure that there will be no conflict with the current service user group. EVIDENCE: The homes statement of purpose and service user guide both included the categories of service user that the home can admit under its registration. Sizes of rooms, and details of the proprietor, manager and staffing rations were also identified. This gives prospective service users some indication of the support that they could access through the services at the home and decide if the room allocated to them was big enough fore their needs. The inspector observed the case files of three service users. These all included comprehensive assessments of the service users individual needs. The assessment information was a combination of the homes pre-admission assessment, care management and specialist mental health assessments. These assessments made sure that the service users needs could be met at the home. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 9 The inspector’s discussions with service users and visitors to the home, and interviews with management and staff confirmed that the home has the capacity to meet the needs of the service users. This information was also supported through the training records of the staff at the home. The records indicated that all of the mandatory training and specialist mental health training is provided to the staff and they are regularly supervised to monitor the care that they are providing to the service users Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 and 10 The service users are able to make choices for themselves throughout their daily activities. EVIDENCE: The inspector observed three service users care plans. The needs identified in the care plans were directly related to the needs identified through the service user original assessment of needs. All of the case files observed by the inspector also included care management care plans. The homes care plans also reflected the needs identified by the care management team. Two of the three service users care plans had been evaluated on a monthly basis to ensure that there were no changes required to the care that they received at the home. The third file had not been evaluated on this basis. This could mean that the service user individual was not having their needs met in the home as the staff could not ensure that the service users needs were being recognised. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 11 All of the care plans that the inspector observed also included where necessary appropriate risk assessment. This included use of public transport and accessing activities in the community. Risk assessments were in place where they were required however some of them would benefit from including greater detail of the risk to service user or others around them and the plans to minimise these risks. The service users case files and interviews with the same service users confirmed that they mare supported and encouraged to make decisions for themselves throughout their daily activities. This includes choosing the decoration for their individual rooms, times to rise and retire to bed and what and where to eat. All of the confidential information at the home was held in accordance with the Data Protection Act 1998 and was held safe and secure. Service users spoken to by the inspector were aware that records were held in the home in relation to their individual care and that they could access this if they wanted to. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15, 16 and 17 The service users have the opportunity to develop their choice of lifestyle including the activities that they become involved in at the home or in the community. These activities provide the service users with opportunities to support their personal development. EVIDENCE: The care plans observed by the inspector, diary records and discussions with service users confirmed that the service users where appropriate are supported to undertake work experience placements, continue with their education and become involved in fulfilling activities. Recently an anonymous complaint was made to the Commission in relation to the homes activity records stating that the activities recorded were actually fictitious and did not actually occur. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 13 The complaint was investigated by the Commission and was not upheld. The activity records were observed and the inspector spoke to service users recorded as accessing the activities and they confirmed that they had been involved in the activities. Some of the activities were also supported through photographic evidence of the events. The activities are balanced between events in the home and out in the local community. Service users stated that they often access the local community and that they were well known in the local shops. The activities were quite varied including quizzes, European days (staff and service users dress up and eat meals associated to different regions.), picnics, trips to the cinema and local walks. All of the activities provided promote the service users independence and freedom of movement. The home does not provide the service users with an annual seven-day holiday as part of the service users basic contract price (NMS 14.4). The inspector ate with the service users. The mealtime was unrushed and service users were provided with a choice of meal that were nutritious. The service users stated to the inspector that they were happy with the meals that are provided for them at the home, and that they are often approached to identify what foods they would like including on the home menus. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The service users personal needs are met by the home and their healthcare needs are met through professional support that is based in the community. EVIDENCE: The home does not provide nursing care and this is identified in the homes statement of purpose and service user guide. Individual service users case files identified the healthcare professionals that are supporting their individual healthcare needs. This included consultant psychiatrists, GP’s, community psychiatric nurses and district nurses. Service users stated to the inspector that when they see professionals for their healthcare needs this is always done in private and the staff are only present if the service user requests that they attend the meeting or appointment. A nurse visiting the home stated that the home were very pro-active in alerting healthcare service when their was a deterioration in a service users physical or mental health. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 15 The inspector observed the administration and records of the prescribed medication in the home. The Medical Administration record sheets were all up to date and were accurately recorded. Staff training records, and interviews with management and staff of the home confirmed that staff administering medication to service users receive appropriate accredited medication training. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The service users are protected from abuse and there is a clear and open policy for service users to complain about the services that they receive through the home. EVIDENCE: There had only been one complaint recorded since the last inspection in relation to the home and this was made directly to the Commission. As detailed earlier in the report the complaint was anonymous and referred to the homes activities. The complaint was investigated by the Commission and was not upheld. The staff at the home receive protection of vulnerable adults training that is provided through the local authority. Staff interviewed by the inspector were knowledgeable in relation to abuse issues, and knew how to report suspected abuse. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25,26,27,28 and 30 The service users are provided with a generally safe environment that is well maintained and is free of offensive smells. The radiators in the home are not protected with low temperature surfaces and this could put the service users at risk of scalds and burns if their skin contacted them. EVIDENCE: Service users spoken to by the inspector stated that their bedrooms were sufficient to meet their needs. Rooms that the inspector was invited to see by the service users were all personalised to their own tastes and preferences. The service users also stated that when their bedrooms are redecorated they are consulted as to what they would like. The toilets and bathrooms in the home are situated close to the bedrooms and communal areas. There are plans at the home to redevelop one of the bathrooms to include a shower unit to give the service users more choice in the way in which they want to maintain their personal hygiene. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 18 The home has a range of communal areas including a separate smoking room. Service users stated that they could choose to use any of the communal areas however the majority of the service users have fixed positions that they prefer in each lounge. Service users also stated that they usually choose to sit in the same positions at mealtimes in the dining room. The inspector’s tour of the home confirmed that it was clean, tidy and was free of any bad smells. The home does not have a sluice facility however the washing machine in the laundry was programmable to disinfection and sluicing standards. The radiators in the home were not all provided with low temperature surfaces. This could put the service users at risk if their skin came in to contact with these surfaces. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 and 36 The home has an effective staff team that understands the needs of the service users and the service users have confidence in the skills and abilities of the staff team. EVIDENCE: The staff and management of the home have a commitment to achieving a minimum of 50 of the staff to have achieved NVQ 2 or equivalent by 31st December 2005 The staff training records and interviews with the staff confirmed that they had a knowledge and understanding of the needs of service users experiencing mental health problems. The service users stated that the staff are very helpful and respectful towards them. The inspector observed the personnel files for three members of staff. These all included the required information including the original job application form, records of the interview process, two written references and copies of personal identification documents. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 20 Staff that were interviewed by the inspector confirmed that their employment at the home had followed equal opportunity procedures. New staff appointed to the home receive an induction package. The induction programme had been cross-referenced to the requirement of the Sector Skills Council workforce training targets. Staff supervision records indicated that they are not quite maintaining that all staff receive the minimum of six formal recorded supervision periods a year. This could mean that service users care plans are not being monitored appropriately and their changing needs may not be identified. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,41,42 and 43 The management of the home is open and approachable to the service users, family, carers and outside professionals. EVIDENCE: The management of the home is open and there is good access to the manager and deputy manager. The service users confirmed that the manager has an open door policy and that she is very supportive. Direct observations also supported that the service users have the confidence to approach the management of the home and were comfortable when communicating with them. The homes quality assurance and monitoring system has improved since recent inspections however the system has not yet been completed. Quality surveys have been completed through a series of questionnaires to service users including topics such as their environment and their individual rooms. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 22 The responses to the questionnaires need to be analysed and an action plan needs to be developed from the findings. The completed analysis and action plan should then be published. The records held by the home were all stored in accordance with the Data Protection Act 1998. The written information was also all up to date and accurately recorded the daily services and activities being provided through the home. The home would benefit from consolidating some of its written documentation as currently the system is fragmented and causes the duplication of information being recorded in different areas, and at times can lead to some confusion of what information should be recorded where. The majority of the homes health and safety requirements were met with the exception of two areas the hallway ceiling was missing following some plaster falling from the ceiling in to the hallway, and the homes radiators, and hot water pipes are not provided with low temperature surfaces. This could cause injury to the service users if they came in to contact with these hot surfaces. The top floor of the home continues to be used as the offices for the homes sister company that provided homecare services. This means that staff working for the service, and visitors to the homecare service have to access it through the home. This impinges on the lives of the service users living at the home. Service users stated that they were used to seeing the homecare service staff at their home and it did not interfere with their lives to any great extent. The greater concern would be that visitors to the homecare service would not all have an enhanced CRB clearance and could have access to a very vulnerable group of adults. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 x 3 x Standard No 31 32 33 34 35 36 Score x 2 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbridge House Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 x 3 1 1 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 24 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 6 Regulation 15 Requirement The registered person must ensure that all individual care plans in the home are evaluated on at least a monthly basis to ensure that they are still appropriate to meet the needs of the service users.Timescale for 30th June 2004 was not met. The registered person must make a seven day holiday avaiable to all service users on an annual basis. This must be included in their basic contract price. The registered person must ensure that the ceiling in the hallway is repaired. The registered person must ensure that all radiators and hot water pipes in the home are provided with low temperature surfaces to protect the service users against scalds and burns. The registered person must ensure that a current business and financial plan is open to inspection to ensure the effectiveness, the financial viability, and accountability of the home. The timescale for 30th December 2004 was not met. 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Timescale for action 12th December 2005. 2. 14 16 31st March 2006. 3. 4. 42 42 12 12 15th september 2005. 30th November 2005. 5. 43 7 30th september 2005. Westbridge House Version 1.40 Page 25 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. 3. 4. Refer to Standard 32 36 37 39 Good Practice Recommendations The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent by 31st December 2005. The registered person must ensure that all staff working in the home the minimum of six formal recorded supervision periods per year (pro-rata) The registered person must ensure that the manager of the home has completed the Registered Managers Award or equivalent by 31st December 2005. The registered person must ensure that the home has an appropriate quality assurance and monitoring system that can identify any deficits or good practice points in the services that are provided through the home. Westbridge House 20050901 Westbridge House x100023 UI J54 v246181 s2890 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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