Inspection on 25/04/05 for Westbrook House

This inspection was carried out on 25th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westbrook House 11/04/07

Westbrook House 12/04/06

Westbrook House 09/11/05

Westbrook House 18/11/04

Westbrook House 03/06/04

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Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Westbrook House Cupid Green Lane Hemel Hempstead Hertfordshire HP2 7GH Lead Inspector Angela Dalton Unannounced 25 April 2005 10:30 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. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westbrook House Address Cupid Green Lane Hemel Hempstead Hertfordshire HP2 7GH 01442 264965 01442 264965 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) Caretech Community Service Limited To commence Registration process Care Home 8 Category(ies) of LD LD Learning Disability - 8 registration, with number PD PD Physical disability - 8 of places Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for 8 people with a learning disability (aged 18-65 years and over 65 Date of last inspection 18th November 2004 Brief Description of the Service: Westbrook House is situated between the Grovehill and the Woodland Farm areas of Hemel Hempstead and is within five minutes from the local shops, Health Centre and General Practitioners. The property is a conversion of a listed, two-storey farm building. It has been refurbished to a very high standard to provide for the needs of a highly dependent group of service users. The ground floor contains eight single bedrooms; each designed with the potential care needs of the service users in mind, 2 assisted bathrooms, 2 toilets and a laundry room. The lift provides access to the first floor, which consists of a lounge, dining area, kitchen, shower and toilet facilities. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was a positive one where all but one of the previous requirements was met. Staff interacted with service users and the inspector observed activities taking place. What the service does well: What has improved since the last inspection? What they could do better: Staff have no computer access nor do service users. Staff are therefore unable to complete any paperwork in house and any documentation requiring typing is sent to head office. Service users would be abe to access software that would Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 6 convert words into pictures if a computer were available to them. Medication systems requires improvement when initially received into the home; when recorded and when medication is amended so that it is possible to complete an audit to ensure service users have received their medication correctly. To ensure the safety of service users the use of electrical extension leads should not be used. A leglonella check also may need completing, the manager needs to investigate this further. It was not possible to verify that service users are protected by robust recruitment procedures as recruitment files are not kept in the home. 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. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 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 Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 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) 1,2,3,4,5 Service users are equipped with the information needed to make an informed choice about where they live. EVIDENCE: The home has had no new admissions but introductory visits would be available should the situation arise. The manager plans to review the current Statement of Purpose to ensure that all information is up to date. Assessments were conducted prior to service users moving into the home and provided the basis for comprehensive care plans. This enables the staff to fully meet service users needs and identifies the training that staff may require. All service users have a contract in a format that they can understand. This states the terms and conditions of the home which ensures service users know their rights. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 9 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) 6,7,8,9,10 Service users have individual care plans which ensure that full participation within the home occurs. Service users are encouraged to take risks with staff support and to be as independent as possible. EVIDENCE: Each service user has a detailed plan of care which is written from their perspective. This guides staff through each need that an individual has and how this should be met. Choices are recorded and it is evident that service users are consulted about all aspects of their lives. Information is regularly reviewed to reflect any changes in service users’ requirements. Regular one to one meetings take place with an agenda to ensure that all service users are aware of the developments within the home and to seek their views Comprehensive risk assessments are in place which reflect that service users participate in activities of their choice. Staff are aware of confidentiality and this forms part of their employment contract and is revisited in supervision. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 10 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) 11,12,13,14,15,16,17 Service users have appropriate and fulfilling lifestyles. EVIDENCE: The home employs a daycare co-ordinator who ensures that service users participate in meaningful activities. Some service users attend a daycare provision but none are employed. A full programme of activities takes place and the home is in the process of advertising for a driver to facilitate more outings. Service users participate fully in the community and visit local facilities such as the pub and cinema. Staff ensure that outings are not confined to the hours that the daycare co-ordinator works to provide choice to service users. Family and friends play an important part within the home and links are supported and encouraged by staff. Staff knocked prior to entering bedrooms to observe service users’ privacy. Bedrooms are personalised and equipped with aids and adaptations to support individual needs. One service user is supported to keep goldfish in their bedroom. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 11 Mealtimes have recently been reviewed and a cook is no longer employed. Staff support service users to prepare meals. A dietician visits regularly to support staff in menu writing and ensure nutritional content of meals is appropriate. As noted in the previous inspection report service users have to contribute financially to any hollidays as they are not included in the basic contract price. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 12 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) 18,19,20,21 Service users receive appropriate healthcare and personal support. Medication procedures require attention. EVIDENCE: Service users needs and wishes (e.g. funeral plans) are recorded in their care plan and reviewed and monitored where necessary. Other professionals, such as the District Nurse, Physiotherapist and Community Nurse liaise closely with the home to ensure service users receive the care and support that they need. Medication amounts were not recorded on the Medication Administration Record Sheet when they were checked in. Checks on amounts could not be conducted. Although there is a thermometer in the medication cupboard temperature records are not kept and correct storage temperatures cannot be assured. Handwritten instruction on Medication record sheets have not been signed and authenticity cannot be checked. Gaps were on sheets which reflected that medication had not been given or hadn’t been signed for – the risk existed that someone may be overmedicated. One service user had not received their prescribed medication due to a repeat prescription not being issued. A requirement has been made Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 13 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) 22,23 There is a clear and effective complaints policy. Service users are protected from abuse. EVIDENCE: The complaints policy is in a pictorial format to ensure service users can use and understand it. The contact details of the Commission should be updated. Following recent events within the home procedures have been reviewed regarding protection of service users. All staff have received Adult Protection training in staff meetings and in one to one supervision sessions. Although, all staff should also attend the Hertfordshire County Council Adult Protection training so that they work within the agreed multi agency guidelines. Finances are securely stored and on checking were found to be accurately recorded. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 14 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) The premises are suitable for the needs of the service users. EVIDENCE: The home was clean and odour free. Service users have access to the aids and adaptations that they require to maximise their independence. A physiotherapist was visiting during the inspection to provide a new wheelchair. The garden is being altered to make it more accessible to service users and they are participating in this process as part of in house horticulture sessions. Each bedroom reflects the individual’s personality with belongings that they have chosen. The manager is exploring infection control training. It is recommended that paper towels are kept in service users’ bedrooms where invasive procedures take place to maximise infection control. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 15 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) 31,32,33,34,35,36 Staff numbers and skills are sufficient to meet the needs of the service users. Service users are not safeguarded by the Company’s recruitment process. EVIDENCE: The use of agency staff within the home has decreased, as the recent recruitment campaign for staff has been successful. Records for all staff were not on site so the inspector was unable to validate that references had been received and Criminal Record Checks had taken place. Service users remain vulnerable until this assurance is provided to the Commission. Staff have ongoing training to ensure that they are equipped to meet service users’ needs. Some staff have achieved their NVQ award and the manager is working towards achieving her managers’ NVQ award. Regular one to one supervision occurs within the staff team to ensure that staff are receiving support and are able to meet service users needs. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 16 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) 37,38,39,40,41,42,43 The home is well run and the company monitor’s this. The health and safety of service users is compromised. EVIDENCE: The manager is currently working towards the Registered Manager’s Award. She has submitted her application for registration with the Commission for Social Care Inspection. Staff confirmed that the manager was accessible and approachable. CareTech audit the home every six months to ensure that a satisfactory level of care is offered to service users. The result of their quality assurance exercise are given to the home manager and shared with the team. This ensures that all staff are aware of any improvements needed. Policies and procedures are distributed by head office and staff are invited to comment. Records checked (quality assurance, accident, fire, complaint, financial, training) were found to be in good order. This evidenced that health and safety checks are conducted. There was no evidence of whether a Legionella check is necessary and the Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 17 manager will explore this. Extension leads are still in use for the majority of the service users and in other areas of the home. The safety aspect of this practise must be professionally checked and evidenced to the Commission. Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 18 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 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 2 2 Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbrook House Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 19 Yes 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 YA 24 YA 42 Regulation 13(4) Requirement The health and safety of service users is compromised. The use of extension leads within the home must be checked by a qualified person to ensure that it is safe. This issue was raised at the previous inspection. The manager must research whether a Legionella check is required and inform the Commission of the outcome and any associated action required. Timescale for action 31/05/05 2. YA 20 13(2) Medication amounts must be recorded when new medication arrives or is carried forward to ensure numbers can be reconciled. All medication given must be signed for and no gaps left. Medication must be ordered in sufficient quantities and service users must not be left with out prescribed medication. Medication storage temperatures must be recorded and kept within the correct range. Handwritten medication 31/05/05 Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 20 instructions must be signed (preferably by a G.P.) 3. YA 34 17 (2) Schedule 4 Recruitment records must be kept within the home. 31/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA 14 YA22 YA23 YA30 YA20 Good Practice Recommendations Holidays should be incorporated into the basisc contract price. This recommendation was made at the previous inspection. Details of the Commission should be updated in the Complaints procedure. This recommendation was made at the previous inspection. Staff should attend Hertfordshire County Councils Adult Protection Training. Disposable handtowels should be in place in bedrooms where invasive procedures occur. A safe system of holding the managers office door open should be employed to assist in medication being stored at the correct temperature the office currently becomes very warm. A computer should be purchased for service users use. This recommendation was made at previous inspections. 6. YA29 Westbrook House I52 s19613 Westbrook House v222772 250405 stage 4 .doc Version 1.30 Page 21 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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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