Inspection on 06/09/05 for Westbrook House

This inspection was carried out on 6th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westbrook House 16/05/07

Westbrook House 11/01/06

Westbrook House 22/10/04

Westbrook House 12/05/04

Westbrook House 22/10/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Westbrook House 21 Cabbell Road Cromer Norfolk NR27 9HY Lead Inspector Lella Andrews Unannounced 6 September 2005, 12:45 th 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 I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westbrook House Address 21 Cabbell Road, Cromer, Norfolk. NR27 9HY. 01263 512482 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) Jeesal Residential Care Services Limited Mrs Shirley Luke Care Home 7 Category(ies) of Learning Disabilities (7) registration, with number of places Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seven (7) adults, of either sex, with a learning disability may be accomodated. Date of last inspection 22nd October 2004 Brief Description of the Service: Westbrook House is a four storey house situated in a residential street in Cromer. It provides accommodation for up to seven adults with a learning disability. The Home has a communal lounge, dining room and kitchen on the ground floor. There are seven single bedrooms on the first and second floor. The basement provides an activities room and office space as well as an additional WC and shower. The Home has a patio with seating to the rear of the Home and a very small seating area to the front of the Home at basement level.The Home is situated next to communal gardens and is very close to the seafront and to the town. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and took place between 12.45 and 3.45pm on Tuesday 6th September 2005. The Manager was present for the majority of the Inspection. The Inspector spoke to three of the tenants and was shown around the communal areas of the Home. The Inspector spoke to two members of staff on an individual basis. Records were also inspected. There will shortly be a change in the management of the Home. The current Manager will be reducing her hours at the Home and the role of Manager will become a job share between herself and the previous deputy manager of the Home. The staff and tenants are aware of this and seem to be quite happy with the proposed change. What the service does well: The staff know the tenants well and have a good knowledge of how to meet their needs. The staff are enthusiastic and caring about individual tenants. The health needs of the tenants are given a high priority and staff work hard to ensure that these needs are met in the most effective way. Tenants are supported to develop and maintain their independence in a range of areas. Tenants are supported to take part in a range of leisure and educational activities. The medication procedures promote the health of the tenants. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were measured EVIDENCE: N/A Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 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) 7 and 8 The tenants are given support to make decisions about their lives and are encouraged to participate in all aspects of life in the Home. EVIDENCE: The majority of the tenants living at the Home have communication difficulties and the staff use other forms of communication in addition to speech. For example, objects of reference are used for one of the tenants who also has a visual impairment. Symbols and sign language are also used with different tenants. Staff are aware of the importance of communication and work hard to enable the tenants to communicate their wishes effectively. Staff were seen to spend a long time trying to ascertain the preference of one of the tenants with regard to what they wished to do. The procedures in place for staff to look after tenants money was inspected for two of the tenants. The care plans include a risk assessment and the individual tenants involvement in the process is based on this assessment. For example, one of the tenants looks after a certain amount of their own money and signs the financial records that are kept whilst another tenant is unable to be responsible for their own money and so the staff look after every aspect of Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 10 this. Appropriate records are kept although it is recommended that the record of benefits received by each tenant is updated. The cash held was checked for one of the tenants and was correct. The tenants are invited to join a tenants meeting at which aspects of life in the Home are discussed. Tenants are encouraged to take part in household tasks and said that they had been involved in choosing the colour scheme for some of the recent decoration work that has taken place in the Home. There is a display in the entrance hall which contains photographs of the staff on duty and there is also a display which shows, in symbol format, the activities that each tenant will be doing each day. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 11 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) 13, 14 and 16 Tenants are supported to take part in a range of leisure and educational activities within the local community. The tenants rights are respected and staff work hard to ensure that tenants understand if there are reasons why they may be unable to do something that they wish to do EVIDENCE: The Home is situated very close to Cromer town centre and to the seafront. All of the tenants need staff support to go out and the staffing rotas are flexible to ensure that additional staff are on duty at times when activities are taking place. One of the tenants attends a formal day service for one day per week. All of the tenants have a weekly plan of activities which may include adult education classes, gardening, music, sailing, shopping. The tenants also told the Inspector about a range of leisure activities that had taken place over the summer, including holidays, meals out, theatre trips, walks and attendance at local community events. One of the tenants showed the Inspector photographs of their recent visit to a Caribbean carnival. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 12 Staff work hard to ensure that the tenants are able to take part in planned activities and are enthusiastic about finding out new activities that the tenants might enjoy. The staffing levels have been reduced at times over the previous three weeks due to staff taking holidays and also staff sickness. The staff advised that they had still enabled the tenants to take part in the planned activities but that this had been difficult at times. Staff advised that tenants are able to get up and go to bed at times of their own choosing. Tenants were seen to make their own decisions about where they spend their time in the Home. Two of the tenants showed the Inspector their bedrooms and these are comfortably furnished with seating, music systems and televisions. Two store rooms in the basement have been altered into a large activity room and the tenants are able to use this whenever they like. One of the tenants has their drum set in this room and is able to play these when he chooses to. Tenants have a risk assessment with regard to whether they are able to hold the key to their bedroom. Staff were seen to knock on doors prior to entering rooms. Staff are aware of the need to respect the privacy of the tenants and gave examples of this. Only one of the tenants smokes and they understand the arrangements that are in place for this. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 13 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 and 20 Tenants receive personal support in the way that they prefer. Tenants physical and emotional health needs are met. Tenants are protected by the Homes policies and procedures for dealing with medicines. EVIDENCE: The tenants require varying levels of personal care support and this is clearly recorded in their care plan. Tenants are encouraged to develop and maintain as much independence as possible with regard to this area. The tenants are encouraged to develop their own sense of style and staff are aware of the importance of enabling the tenants to make their own choices, as far as possible, with regard to clothing, hairstyles and make up. The bedrooms reflect the individual styles of the tenants. The staff work hard to ensure that the health needs of the tenants are met. One of the tenants has had some particular health problems recently and the care plan contains detailed information about the steps taken to meet these needs. The care plan contains evidence of a range of health professionals being involved in the process and of the monitoring of situations that is Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 14 undertaken by the staff at the Home. Staff gave examples of how they have tried to ensure that the tenant understands their current health issues. The staff are caring and have good relationships with the tenants. They have a good knowledge of how to meet the needs of the tenants and of the information contained in the care plans. The medication system was inspected. The monitored dosage system is in place and the medication is stored appropriately. Records are kept of medication received at the Home and of that returned to the pharmacy. The care plans contain information about the medication that each of the tenants is prescribed. All staff who are responsible for the administration of medication have received training provided by the organisation. The acting Deputy Manager is taking a particular interest in the medication and has introduced a consent form in symbol format which can be used by some of the tenants. This is good practice. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 15 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) 23 Procedures and staff training are in place to protect the tenants from abuse. EVIDENCE: The Home has extensive policies and procedures which aim to protect the tenants from any form of abuse. The staff are required by the organisation to read these documents on a six monthly basis. Staff who spoke to the Inspector have received training with regard to the Protection of Vulnerable Adults and are aware of the whistle blowing policy. Staff are confident that the Manager will deal appropriately with any concerns notified to her. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 16 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) 24, 25, 26 and 28 The tenants live in a homely, comfortable and safe environment. The tenants bedrooms suit their individual needs and they have the use of a range of communal rooms. EVIDENCE: There has been a lot of improvements to the environment since the previous Inspection. The hall area on the ground floor had previously been quite a dark area but now the doors have been replaced with doors of a lighter colour and magnetic catches have been fitted to the dining room and lounge doors so that these can be open if the tenants wish them to be. A glass panel has been put into the kitchen door and the door leading to the stairs which again brightens up the hall area. The dining room has been decorated and has attractive new furnishings. As previously mentioned, an activity room has been refurbished and decorated in the basement and provides a nice room for tenants to use individually or for group activities. The basement still also provides an additional activity room Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 17 and meeting room which are often used by groups from other Homes owned by the organisation. New flooring has been put into one of the bedrooms on the second floor and the shower room on this floor has been refurbished. The bathroom on the first floor has been refurbished and is in the process of being redecorated. One of the bedrooms on the first floor has had an ensuite added which provides a toilet, handbasin and corner bath which is a positive addition for the tenant. There is still ongoing redecoration work in this bedroom which is not quite finished. There is an ongoing programme of refurbishing and redecoration of the tenants bedrooms and one of the tenants showed the Inspector their new wardrobe and bed. The Home does not have a garden but has a patio area to the rear of the Home which is adjacent to large communal gardens. Work is being carried out to alter the steps from the kitchen into the patio area as they are currently rather steep. This will improve access for the tenants to this area. The Home has double glazed windows and it was noted that some of these appear to have condensation between the panes of glass. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 18 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) 33 The tenants are supported by an effective staff team but more steps need to be taken to ensure that additional staff are available to cover for holidays and sickness EVIDENCE: The Home has a stable staff team who receive good support from the Manager and training appropriate to their role. There are usually two staff on duty throughout the day with additional staff on duty to enable specific activities to take place. However, the rotas show that for the previous three weeks there have been occasions when, for short periods of time, there has only been one member of staff on duty. This clearly reduces the opportunities to enable tenants to go out or to undertake one to one time with tenants within the Home. It is understood that this situation is a temporary one due to staff being on holiday and additional staff sickness. However, steps must be taken to address the situation. There is a sleep in member of staff on duty at night and additional support can be sought from the on call manager if required. Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 19 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) None of these standards were inspected EVIDENCE: N/A Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 20 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 x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 x x Standard No 11 12 13 14 15 16 17 x x 3 3 x 3 x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbrook House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 21 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 33 Regulation 18 (1a) Timescale for action The registered person must Immediate ensure that sufficient staff are on and duty at all times ongoing Requirement 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 7 Good Practice Recommendations It is recommended that the records of benefits received by the tenants are updated Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 Westbrook House I55 s27329 Westbrook House v241736 UN 060905 Stage 4.doc Version 1.40 Page 23 - 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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