Inspection on 22/02/06 for Westbridge House

This inspection was carried out on 22nd February 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 2 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 20/10/06

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 ADULTS 18-65 Westbridge House 1 Westfield Road Barton On Humber North Lincolnshire DN18 5AA Lead Inspector Stephen Robertshaw Unannounced Inspection 22nd February 2006 09:30 Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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.V272519.R01.S.doc Version 5.1 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 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.V272519.R01.S.doc Version 5.1 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.V272519.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 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 companys 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. Since the last inspection the home care services have acquired new accommodation and will shortly move in to it. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 22nd February 2006. The inspection was over a six and a half hour period. The evidence for the report was gathered by the inspector through observation of records in the home, discussions with service users, interviews with management and staff and direct observations. The inspection was very positive and the majority of the homes National Minimum Standards were met. Two standards were exceeded. The staff, management and service users were all very open with the inspector and the atmosphere of the home was observed to be very relaxed and homely. What the service does well: The home provides clear information to prospective service users and their families of the services that are available at the home. Westbridge House staff receive regular training to make sure that they can meet the needs of the service users. This includes specialist training in relation to the mental health needs of the service users. The service does not provide nursing care however the records in the home supported that the staff maintain good contact with outside professionals to ensure that the healthcare needs of the service users are met. The environment is maintained well and a tour of the premises found it to be clean and free of any bad smells. The tour also identified that individual service users rooms had been personalised to their own tastes and preferences. 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. Two of the National Minimum Standards were exceeded by the home this included the openness of the management and the administration and record keeping for the medication system that is used in the home. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 DS0000002890.V272519.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 2,3,4 and 5 The service users are provided with an opportunity to visit the home to decide if they wish to reside there and then they are provided with choice throughout their daily lives in the home. EVIDENCE: The inspector observed the case file records for three of the service users living at the home. All of these files included comprehensive assessments of the service users individual needs. The assessments were a combination of the homes pre-admission assessments and assessments of needs provided through the funding authorities. The assessments were all appropriate to the needs of the service users, however a regular respite care service users did not have their needs reassessed when they are admitted to the home to ensure that their care plans remained the same as for previous admissions. The home has the capacity to meet the assessed needs of the service users this was confirmed through the records observed by the inspector. This was also supported through discussions with the service users and records of contact with professional healthcare workers that are based in the community. The service users spoken to by the inspector confirmed that they were given the opportunity to visit the home before they made a commitment to live there on a more permanent basis. The service users stated that the visits were between a couple of hours and overnight stays at the home. This had given Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 9 them the opportunity to meet the other service users and the staff that work at the home. The service users case files all included terms and conditions of their residency at the home. This included terms of the notice required if a placement at the home was to be terminated by either the service users or the management of the home. The files also included contracts and terms and conditions of the service users placement at the home provided by the funding authorities. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 6,8 and 9 The service users are provided with choice throughout their daily lives at the home. EVIDENCE: The inspector observed the care plans for three of the service users living at the home. There was a clear improvement in the quality of the information recorded in the care plans and in the detail of how individual needs must be met. The manager of the home stated that in the homes attempt to gain the local authorities quality mark she had submitted a sample of the homes new care plans to the manager of a management team for their approval. Some comments were seen to have been returned and the manager was incorporating some minor changes to the set up of the care plans as recommended by the local authority in relation to their quality award. Once agreed by the home and care management this system will be implemented for all of the service users living at the home. The homes care plans met all of the service users individual needs that were identified through their original assessments. The home uses a keyworker system and all of the service users spoken to by the inspector were aware of who their keyworker Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 11 was and what their responsibilities were. The care plans had all been evaluated on a regular basis to ensure that the service users needs were continuing to be met at the home. Records in the home confirmed that the service users are given opportunities to participate in the development of the services that are proved in the home. This included records of very regular service user meetings. These are held on a monthly basis in the home. The service users are also involved in the homes quality monitoring group and the inspector also observed the records for these meetings. The service users spoken to by the inspector confirmed that these meetings had taken place and that they were given the opportunity to air their opinions in relation to the services that are provided in the home. Risk assessments were observed by the inspector that supported the care plans for individual service users. The risk assessments were a combination of the homes risk assessment process and Care Programme Approach risk assessments provided through the placing agencies. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 11,13,14,15 and 17 The service users are supported to maintain and further develop their personal lifestyles while living at the home. EVIDENCE: The care plans observed by the inspector showed how the service users are supported and encouraged to maintain and develop their social, emotional, communication and independent living skills. Service users confirmed to the inspector that they are supported by the staff and management to remain as independent as possible while they are living at the home. The service users stated that they have very good access to services in the community. This included access to adult education facilities and a local café where a luncheon club and bingo is held once a week. Other service users said to the inspector that they regularly attend day centres that are based in the community. The service users do influence how activities are provided in the home and in the community however this can be limited at times due to the poor Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 13 concentration and commitment of individual service users in relation to their mental health problems and the lack of availability of activities in the local area. Service users case files showed that they have regular contact with their families and friends and they are supported by the staff to maintain these relationships. The service users confirmed to the inspector that when they receive visitors at the home they are always seen in private. The staff at the home make sure that the service users are provided with a varied and balanced diet. Quality assurance questionnaires were distributed to the service users in relation to the meals that are provide for them and the returns supported that the service users are happy with the range and quality of meals that are provided in the home. The kitchen was clean and there were good stocks of food in the home. Since the last inspection three of the homes freezers had been replaced, the storerooms walls had been tiled and new storage shelves had been fitted to the walls. Service users spoken to by the inspector stated that they were happy with the meals that are provided at the home and that they always got the amount of food that suited their individual needs. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 18,19,20 and 21 The service users personal and healthcare needs are met at the home. EVIDENCE: National Minimum Standard 20 was exceeded. The home does not provide nursing care to the service users. Healthcare needs of the service users are met through healthcare professionals that are based in the community. This included GP’s, community psychiatric nurses, district nurses, psychiatrists and dentists. Service users case file records and discussions with service users supported that all of the healthcare needs are met through appropriate healthcare professionals either at the home or in the community and that their privacy, dignity and independence was supported at all times. NMS 20. All staff that administer medication to the service users have received accredited training and staff training records showed that they had all successfully completed the training. The medication record sheets were all up to date and were accurately recorded. Two staff administers the medication and sign the records to eliminate the possibility of any errors. Individual service users medication records have their photograph attached to it to Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 15 ensure that a visual picture so the staff are able to check this with photographs on the service users care files if they were unsure who the service users were. The three care files that were observed by the inspector identified their wishes in the event of their deaths. One of the files clearly identified that they service user or their family did not wish to consider this at this time as it was too distressing for them to consider. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 The complaints procedure is accessible to the service users and policies and procedures are in place to protect them from possible abusive situations.. EVIDENCE: The management of the home clearly record any complaints that are made in relation to the services that are provided. Niggles and concerns are also recorded. Since the last inspection one complaint had been made directly to the Commission however none of the elements of the complaint were upheld. This included a complaint that service users were paying for their meals, the activities records were falsified, medication was given to a wrong service user and that management were never available. There were no formal complaints recorded at the home itself. Staff training records and interviews with staff confirmed that they receive training in relation to the protection of vulnerable adults. The training was provided through the local authority. There have been no protection investigations at the home since the last inspection. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26,27,28,29 and 30 The environment provided at the home is appropriate to meet the needs of the service users. EVIDENCE: The manager was able to produce the certificates for the home that ensured the safety of all of the appliances including the gas, electric and fire safety systems. A certificate from the Environmental Health department was also up to date. The environment is very homely and domestic in character. This included the lighting and furnishings in the home. There was a clear maintenance and renewal programme ongoing at the home. CCTV is not used in the home or in its grounds. The inspector was invited in to several of the service users individual rooms and they had all been decorated to their own tastes and preferences. This also included their won pictures and small items of furniture. The home has twelve single bedrooms and five double rooms. None of these rooms include en-suite facilities. There are two bathrooms and one shower Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 18 room all of these include toilets and are spaced around the home. There are an additional five toilets around the building close to the communal and bedroom areas. The service users have the choice of two lounge areas to socialise in. One of these is a designated smoking area. In addition to these lounges there is also a conservatory that also doubles as a dining area. The majority of the service users at the home are independently mobile and do not require any special aides or adaptations. However the staff have access to a hoist (maintenance records were up to date) and bed rails for the service users if they are required. One service user mobilises with a wheeled walker and two service users have access to wheelchairs to aid their mobility. A tour of the premises by the inspector found it to be free of any offensive smells. Staff interviewed by the inspector were aware of the systems that were in position to control the spread of infection. The washing machines in the home were programmable to disinfection and sluicing standards. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34 and 36 Staff working at the home have the appropriate skills to meet the needs of the service users. EVIDENCE: The inspector observed the personnel and training files for two of the staff working at the home. These both included clearly defined job descriptions and interviews with the staff confirmed that they understood their own responsibilities and those of their colleagues. Staff records showed that they do not commence work at the home with the service users until after they have received appropriate security vetting. There were no volunteers working at the home. The staff have a commitment to attaining their NVQ awards and to achieve a minimum of 50 of the staff to have achieved NVQ 2 or equivalent. The manager stated to the inspector that she hoped that this standard would be met by August 2006. The staff training records also supported that the staff receive specialist training in relation to the mental health needs of the service users. The manager confirmed to the inspector that the Residential forum is used in the home to determine the ratio of staff that are available at any time. Service Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 20 users spoken to by the inspector stated that there are always enough staff available at the home to ensure that their needs are met. The staff files confirmed that the management of the home operates a thorough recruitment procedure that is based on equal opportunities and ensures the safety and welfare of the service users. The personnel files included all of the information required by regulation in relation to individual staff members. This included applications, records of interviews, two written references, personal identification documents and POVA register checks. Staff interviews and files supported that staff formal supervision in the home is now more regular and meets the recommended minimum of six times a year. The staff confirmed to the inspector that their supervision included the philosophy of care in the home, the care plans that they wee involved in working with, professional guidance and personal training and development opportunities. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41 and 42. The conduct of the management of the home ensures the welfare and safety of the service users. EVIDENCE: NMS 38 was exceeded. The manager of the home is close to completing the Registered Managers Award and once this is completed she will begin on the NVQ 4 in care. Direct observations by the inspector, discussions with service users and interviews with staff confirmed that the management approach to the home is very open, positive and inclusive. The home has an effective quality assurance and monitoring system that seeks the views of the service users to meet the needs of the service. The management hold quarterly quality group meetings and these have representatives from the staff group, service users and carers. Regular questionnaires are sent out to different groups of people to access the quality Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 22 of the services being provided to the service users. Summary action plans are created from the responses to the questionnaires and the outcomes are discussed in service user and staff meetings. Graphical pie charts are also created to demonstrate the results from the questionnaires. The homes policies and procedures are reviewed on an annual basis by the manager to ensure that they are up to date and appropriate to the needs of the service users and the home. All of the policies and procedures required by regulation were in position. Staff interviewed were aware of how to access all of the homes policies and procedures. All of the records required by regulation were kept by the home and these were all observed to be accurately recorded and were up to date. The homes health and safety requirements were met. Since the last inspection all of the homes radiators have been provided with low temperature surfaces. Appropriate records were observed for all of the fire systems and the maintenance of them.. There were also up to date safety certificates for the electrical and gas systems in the home and there was appropriate insurance cover for the home and the business. Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 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 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 1 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 3 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 1 4 3 3 3 3 X Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 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 YA32 Regulation 19 Requirement The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent. The registered person must ensure that the manager of the home is appropriately qualified. Timescale for action 15/08/06 2. YA37 9 15/08/06 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 YA2 Good Practice Recommendations The registered person should make sure that respite care service users have their needs re-assessed between new admissions to the home to ensure that the home can continue to meet their needs. The registered person should ensure that the newly developed care plans at the home are introduced for all of the service users in their care. 2. YA6 Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, 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. Extracts may not be used or reproduced without the express permission of CSCI Westbridge House DS0000002890.V272519.R01.S.doc Version 5.1 Page 26 - 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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