Inspection on 20/10/06 for Westbridge House

This inspection was carried out on 20th October 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbridge House 17/10/08

Westbridge House 22/02/06

Westbridge House 01/09/05

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Westbridge House 1 Westfield Road Barton On Humber North Lincolnshire DN18 5AA Lead Inspector Stephen Robertshaw Unannounced Inspection 20th October 2006 09:30 Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 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 Westbridge House DS0000002890.V317293.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 and Care Homes for Adults 18 – 65*. 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. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbridge House Address 1 Westfield Road Barton On Humber North Lincolnshire DN18 5AA 01652 632437 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) Mr Kumar Thakerar Mr Nilesh Lukka Mrs Sandra Cox Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2006 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. Since the last inspection the home care services have acquired new accommodation and have moved in to it. This means that there is no longer a continual disturbance to the service users’ daily lives. The current fee for the care of individual service users at the home is £327 per week. The majority of the service users are placed at the home through local care management and mental health teams. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place on the 20th October 2006. The inspector was in the home for approximately six and a half hours. The inspector observed the written documentation in the home and also contacted professional social and healthcare workers that are based in the community that support the home with the needs of the service users. The Inspector spoke to most of the service users living at the home to see if it was helping them to meet their needs and provided them with a happy and comfortable environment to live in. The inspector also spoke to three visitors to the service and two of the care managers that have placed service users at the home. The inspector also read a lot of the documents and letters in the home that tell how a person is being looked after. The inspector walked around the building and grounds to see what condition they were in and to judge if they were suitable for the service users. What the service does well: The service users have a full assessment of their needs before they are admitted in to the home. This makes sure that the right care is provided to them if they come to live at the home. The service users’ care plans are looked at on a regular basis by the staff to make sure that their needs are still being met and to identify if they need any more or less support than previously given. The manager of the home is always available to the service users, visitors, staff and professionals that access the home. This means that they can all say how the home is doing and what is needed to improve the service that are being provided at the home. The home is kept clean and tidy and there were no bad smells in the home. The staff receive regular training to make sure that they have the knowledge and skills to meet the needs of the service users. The staff have also recently been given new uniforms and name badges. This means that it is easier to identify who is working at the home and reminds the service users and visitors the staff names. Since the last inspection the home has been awarded the local authorities gold award for residential care services. This supports the other information that the home is able to provide quality services to the people that use it. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 6 Visitors are always made to feel welcome at the home. 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. The summary of this inspection report can be made available in other formats on request. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that service users are given the opportunity to visit the home before they make a commitment to move there on a more permanent basis. This includes a full assessment of their individual needs. EVIDENCE: The home’s statement of purpose and service user guide included the details of the manager and the homes proprietor. The information was produced in a Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 9 format that was easy to understand. This also included detail of how to make a complaint in relation to the services provided at Westbridge House. The inspector observed the care files for four of the service users living at the home. All of these files included a full assessment of the service users individual needs completed before they were admitted in to the home. The assessments were a combination of the home’s pre-admission assessments and assessments completed by the service users care management team where appropriate. Service users spoken to by the inspector said that they had been able to visit the home before they moved in to make sure that it was suitable for them. Discussions with visitors to the home, service users, care staff, management, and care management staff, and observation of the documentation in the home all supported the evidence that Westbridge House does have the capacity to meet the assessed needs of the service users. One service user said that ‘Westbridge is the best place I could be in’. Each of the service users’ care files were supported with statements of their terms and conditions for living at the home. Where appropriate this also included their agreements with their placing authorities that also included any third party agreements for contributions towards individual service users’ fees. The home does not have any top up fees. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users’ care needs are well planned at the home, however some of the paperwork did not include the required recognition of signatures for who was included in the completion of them, or full dates when they were completed. EVIDENCE: The inspector observed the care plan information for four of the service users living at the home. The homes care plans had all been developed from the Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 11 individual identified needs of the service users and reflected the needs identified in care plans developed by the service users care management team. The care plans had been signed in agreement to them by the service users or their representatives. This provided supporting evidence that the service users are involved in the development of their care plans. There was also information that supported that service users’ care management teams regularly reviewed the care provided to them at Westbridge House. The care plans had all been evaluated on a regular basis to make sure that the service users Some of the detail included in the individual care plans needs to be improved. All of the paperwork completed by the care staff should all be fully signed and fully dated. The top of diary sheets should include the full names of the service users. The care plans are supported with risk assessments where appropriate. These should also be reviewed on a regular basis to make sure that they are still relevant to the care of individual service users. The care files also include Key worker records of contact with individual service users. These need to be kept up to date to identify more regular key worker input to individual; service users. Service users spoken to by the inspector confirmed that they are able to make decisions for themselves in relation to their daily lives. This include the times to rise from and retire to bed, what to eat and where to eat it and whether or not to become involved in any activities that the home is taking part in on site or ifn the community. Notices were also seen in the home in relation to access to advocacy services for service users. One service user stated that they find it difficult to motivate themselves to do things but the staff ‘encourage and support’ them ‘in a friendly way’ to join in with activities. All of the confidential information kept by the home was appropriately stored in accordance with the Data Protection Act 1998. Service users spoken to by the inspector were aware that records were kept at the home in relation to the care that they received there. They also knew that if they wanted they could have access to this information. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 13 This means that the service users are provided with choice throughout their daily lives and in their activities at the home and in the community. EVIDENCE: Observation of the service user during their daily lives at the home, discussions with them and written documents supported the evidence that the service users are provide with opportunities to maintain and develop their social, emotional, communication and independent living skills. There were no service users living at the home that followed any of their preferred religions. One service user is a Muslim; however, speaking to him and observation of his care plans showed that he does not want to follow any of the dietary or religious needs of his faith. The inspector suggested to the manager and care staff of the home to look in to these areas more closely and involve the service users family more in the development of his individual care plans. Service user care plans supported the evidence that they are supported and encouraged to take part in adult education and take part in valued and fulfilling activities at the home and in the community. There were no service users living at the home whose care plan suggested that they should be supported in to either voluntary or paid employment. Service users spoken to by the inspector said that this wasn’t something that they believed that they could become involved in due to the nature of their illness and how this disabled their daily lives. The service users have good relationships with their neighbours and many of them are known more widely within the local community. One day every week some of the service users attend a local community centre for lunch and then attend activities there in the afternoon. Care staff were observed interacting with the service users throughout the time of the site visit. This was seen to be in a very appropriate and supporting manner and service users preferred terms of address as identified in their care plans were being used. The care staff were observed knocking on service users doors and being given permission to enter before going in. All of the service user individual rooms were lockable. Service users confirmed to the inspector that they had access to all of the home and its grounds and one service user stated that ‘you have to let the staff know when you go out so they know where you are’. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 14 A large percentage of the service users smoke and so one of the lounges has been set-aside for service users to smoke in. A new extraction fan had been fitted to this room and a mobile air purifier had also been added. The service users’ assessments included an assessment of their nutritional needs and diet preferences. This information could be improved by adding more detail in relation to how these needs affected the individual service users and what should be done to support their needs. The inspector joined some of the service users for lunch and they said that the quality of the meals that they received was good and that if they wanted something different then this would be provided for them. The mealtime was relaxed and unrushed and flexible in time. Service users care plans included regular service user weight records as a way of supporting the monitoring of their physical health. Visitors spoken to by the inspector stated that they are welcome to visit the home at any reasonable time and that the staff were always very supportive of them and the service users. One visitor stated to the inspector that since their relative had been admitted in to the home the service users ‘mental health and quality of life had improved’. The home should reconsider its policy on Christmas presents for service users. Currently service users are asked what they want for Christmas then permission is sought to get these things from their savings. As these are wrapped by the staff and a simple name tag is put on them this may appear to others that some service users get more money spent on them than others, when in fact the staff spend how much of the service users’ monies that the service users want spending. This can also cause problems as some service users receive their full benefits while living at the home and others only receive the basic pocket money allowance. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users personal and healthcare needs are met at the home through a combination of support from the homes care staff and outside professionals. EVIDENCE: The service users’ care files included documentation of all of the contact that they had with outside healthcare professionals. This included GP’s, psychiatrists and community nurses. They told the inspector that these Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 16 appointments could always be in private but if they wanted staff to support them then they would. Professionals that visit the service users at the home and see them in the community supported the evidence that they receive all of the healthcare support the service users require, and that the care staff maintained clear and appropriately maintain regular contact with them in relation to the health and personal care needs of the service users. Staff training records showed that they receive specialist training in relation to mental health problems. Direct observations by the inspector supported the other evidence that the service users dignity, privacy and respect are upheld at all times in the home. The service users confirmed that they always have their own clothes returned from the laundry and they choose whichever clothes they want to wear. Some of the care plans included service users being reminded to change and wash their clothes. All of the staff that administer prescribed medication to the service user have received accredited medication training. It is the homes policy that at all times two staff are responsible for the administration and record keeping of the prescribed medication. All of the medication record sheets were up to date and were accurately recorded. There were no service users at the home that were prescribed any controlled medication. The home has appropriate facilities to store controlled medication but it did not have an authentic controlled medication book to record them in. The manager of the home assured the inspector that an appropriate record book would be purchased immediately to meet the requirements in case any prescriptions were received by the home for controlled medication. The service users’ care files include identification of their last wishes in the event of their deaths. Some files included a statement that, due to some service users’ fixations on death and dying, that this information had not been appropriate to gain at this point but would be reconsidered when more appropriate. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are protected from abusive situations at the home and there are clear and easy complaints procedures in position. EVIDENCE: The home has a clear and effective complaints procedure. The procedure was available to the service users on the homes notice board. Service users and visitors spoken to by the inspector were aware of the how to make complaints in relation to the services provided through Westbridge House, however they all stated that they had no call to make any complaints. The home also has a niggles and concerns system and book for service users, visitors or staff to raise smaller issues. Observation of staff personnel files and interviews with staff showed that they had all received appropriate safety vetting before they had any contact with the service users. This included POVA first and CRB clearances. This helps to protect the service users from any possible abuse at the home. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 18 Staff interviews and observation of their training records showed that they receive training specific to the protection of vulnerable adults. This was a combination of internal training, elements of NVQ and Induction training and protection training provided through the local authority. The staff and management were aware of the multi-agency protocols for the protection of vulnerable adults and a copy of the protocols were available in the office of the home. The home also has a clear whistle blowing policy and procedure. All of the staff spoken to by the inspector were aware of what could be seen as possible abuse and how and where to report any allegations or suspicions to. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the environment can meet the needs of the service users however there are areas of the home that require redecorating to enhance its appearance and living situation for the service users. EVIDENCE: Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 20 The home is suitable for its stated purpose. The grounds of the home are limited but in some ways this encourages the service users to make more use of the local community. The home does not have any CCTV cameras that are intrusive on the service users daily lives and activities. The outside of the home is in need of decoration and some of the windowsills require attention as they are beginning to corrode. A window on the second floor of the staircase is badly cracked and has had a temporary repair carried out prior to the last inspection. This window must be repaired/replaced as soon as possible to minimise any risk to the service users living at the home. Some redecoration has taken place in the home including the two lounge areas. However the corridors and individual service users rooms are in need of decoration. Visitors to the home stated that the environment was improving for the service users. The bathrooms are maintained clean and tidy and free of any offensive odours but the equipment is very dated and the home would benefit from updating the present bathrooms and some of the toilets. The bathrooms and toilets are well spaced throughout the home are in close proximity to the communal areas and the service users individual rooms. There is only one service user at the home with any different cultural or religious needs to the other service users. They stated to the inspector that they do not require any cultural fittings or fixtures in any of the bathrooms or toilets. Smoking is limited to a specified lounge at the home. New chairs and air purifiers have been provide in this area. Service users spoken to by the inspector were very happy with their environment especially their own rooms and said that they did not think that it ‘needs much more to make it homely and comfortable’. The home employs a ‘handyman’ who is also shared between the company’s other services. Time at the home depends on prioritising his workload. There are adequate areas for the service users to relax in and to take part in activities. The dining area also doubles as an activity area when meals are not being eaten there. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 21 Service users confirmed to the inspector that they can use their own private areas whenever they choose to and they are not restricted from them due to the time of day etc. The service users living at the home are independently mobile so there are very few pieces of mobility aids in the home. Hoists are available in the bathrooms. The home employs a domestic member of staff. They maintain the home to a very clean and hygienic level. Infection control standards are well maintained in the home. The washing machines at Westbridge House are programmable to disinfection and sluicing standards. The washing machines have automated feeds to minimise the risk of injury to the staff from coming in to contact with the cleaning materials. The floors of the laundry are constructed from an impermeable material that is easy to clean. All of the equipment in the home including the fire safety systems are regularly reviewed, serviced and maintained. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff working at Westbridge House have the necessary skills and knowledge to care for the individual needs of the service users. EVIDENCE: The inspector observed the staff training and personnel files for three of the staff employed at the home. The inspector also spoke to five of the care staff employed at Westbridge House. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 23 The observations and discussions supported the evidence that the staff are employed in line with equal opportunity guidelines and that they receive appropriate safety vetting before they are permitted to have any contact with the service users. This helps to maintain the health and safety of the service users living at the home. There are clear lines of responsibility and accountability in the home and staff spoken to by the inspector were aware of their own responsibilities and those of their colleagues. Staff training and development showed that they receive all of the mandatory training expected of them and that they also receive training specific to the needs of the service user group. Staff confirmed to the inspector that they receive in excess of the recommended minimum of five paid training days per year. The staff have exceeded the requirement for a minimum of 50 of them to have achieved NVQ2 in care or equivalent. Five of the care staff have completed NVQ 2 and a further three staff are awaiting their certificates. A further member of staff is currently working towards NVQ 2 in care. Several service users made the same comment to the inspector that ‘the staff are very helpful’. One service user said that the staff ‘couldn’t do any more for you’ than they already do. Staff stated that they have good working relationships with professionals that are based in the community that have service users in placed in the home. One care manager that was contacted by the inspector stated ‘ the staff communicate well with outside professionals’ and that they ‘have a good understanding of the needs of the service users’. They also stated that the staff at the home were very good at recognising changes in the service users presentations and notified all of the appropriate people involved in their care. Documentation seen by the inspector identified that the staff attend regular meetings to update them on legislation, training and to give them an opportunity to air their views on the development and delivery of the service provided at the home. The staff personnel files supported that the staff receive the recommended minimum of six formal recorded supervision periods per year. Staff interviews confirmed that this actually occurred. The staff have recently been issued with new uniforms and name badges. They stated that this helps to identify them to service users and visitors to the home. Professional visitors said that this ‘was an improvement’. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 25 This means that the management of the home have an understanding of the needs of the service user and the staff groups. However some of the administration of the home’s business affairs could be improved. EVIDENCE: The manager of the home has recently completed the Registered Managers Award and has begun NVQ 4 in care. Since the homes last inspection many of the management systems have improved at the home and through the hard work of the staff and the manager the home has achieved the Local Authorities Gold Award in relation to the quality of care that is provided at Westbridge House. The home is also working towards the Investors in People award. These systems have helped to develop the care planning and staff supervision processes at the home. The manager and staff confirmed that the proprietor of the home is very approachable and supportive of the homes needs. The manager of the home has the autonomy to manage the home and to determine any maintenance that is required to the environment or facilities provided at the home. Training records and interviews with the care staff supported the evidence that the manager refreshers her mandatory and specialist training alongside the staff group. Care managers contacted by the inspector confirmed to the inspector that their access to the manager of the home was very good. Two visitors to the home that were spoken to by the inspector were also very supportive of the accessibility of the management and staff and stated that ‘their support and care’ had improved the ‘quality of life’ for the service user that they were visiting. Staff have recently been provided with new uniforms and name badges. This was as a direct result of a service improvement provided through the returned questionnaires given to the staff group. Menu questionnaires were sent to the service users at the end of July 2006. At the point of the site visit these had net been formally evaluated. Regular staff and service user meetings are held at the home to allow them to air their views on the development and delivery of the services at the home. Records of these meetings were seen by the inspector. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 26 A complimentary letter was sent to the home on 12th October 2006 from a Community Psychiatric nurse. The letter stated that the staff and management of the home had done very good work with a service user to maintain their mental and physical health and in improving their quality of life at the home. The policies and procedures required by regulation were all in place at the home and are reviewed on an annual basis. Although the inspector has no concerns in relation to the home’s financial viability. The homes business and financial plan only went up to April 2006 and needed to be updated. Some records completed in the homes accident book that should have been reported to the Commission had not been reported. This included service users being admitted to the accident and emergency department of the local hospital. This was discussed with the manager and the oversight was recognised and actions were put in to place to ensure that all reports required in the future would be maintained. All of the records required for the protection of the service users were in place, they were up to date and where appropriate were stored in accordance with the Data protection Act 1998. Documentation observed by the inspector supported the evidence that as far as is reasonably practicable the health, safety and welfare of the service users and staff are protected at the home. This included up to date safety certificates for the fire, gas, and electrical systems at the home. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 27 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. 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 4 39 3 40 3 41 2 42 3 43 3 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbridge House Score 3 3 4 3 DS0000002890.V317293.R01.S.doc Version 5.2 Page 28 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 YA9 Regulation 12 (3), 5 (1) Requirement The registered person must make sure that the service users risk assessments are evaluated in conjunction to the care plans that they are associated with. The registered person must reconsider the homes policies on Christmas presents for the service users to avoid any misrepresentation. The registered person must develop the homes nutritional and dietary assessment to include greater and clearer detail of individual needs. The registered person must repair/replace the window with the temporary repair on the second landing of the staircase The registered person must make sure that all reportable incidents are notified to the Commission Timescale for action 30/11/06 2. YA16 20 (3) 30/11/06 3. YA17 14 (1a) 30/12/06 4. YA24 23 (2b) 30/12/06 5. YA41 17 (2) Schedule 4 (!2 a and b) 01/11/06 Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 29 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 YA6 Good Practice Recommendations The registered person should make sure that all care plans are signed by all of the individuals that are involved in the development of them. Use of initials is not acceptable. Full dates must also be included on the documentation. The registered person should make sure that the service users key workers keep more accurate and more regular records of their contact with individual service users. The registered person should consider the redecoration of the outside and several of the corridor areas of the building. The registered person should consider updating the bathrooms in the home in their redevelopment plan. The registered person should make sure that the homes business and financial plan is updated to include maintenance of services and projected developments of the service. 2. 3. 4. 5. YA6 YA24 YA27 YA43 Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 30 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. Westbridge House DS0000002890.V317293.R01.S.doc Version 5.2 Page 31 - 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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