Inspection on 09/11/05 for Westbrook House

This inspection was carried out on 9th November 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbrook House 11/04/07

Westbrook House 12/04/06

Westbrook House 25/04/05

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 Inspection 9th November 2005 11:00 Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 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 Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 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. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 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 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) Caretech Community Service Limited Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 8 people with a learning disability (aged 1865 years and over 65 years) or a physical disability 25th April 2005 Date of last inspection 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 DS0000019613.V264289.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one Inspector on 9th November 2005 between 11am and 3.15 pm. Four service users were at home and the Inspector spent time with them and the staff team. Activity sessions were taking place and staff were engaging with service users. What the service does well: 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 DS0000019613.V264289.R01.S.doc Version 5.0 Page 6 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 Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 7 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): EVIDENCE: These standards were not inspected on this occasion. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 8 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 Service users’ have individual care plans, which reflect their individual requirements. EVIDENCE: Care plans have not significantly changed due to the unchanged group of service users. CareTech have not yet introduced Person Centred Planning that will change the focus of the care plans currently used. The manager hopes to utilise the computer to ensure documentation is more user friendly and symbols are incorporated where possible. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 9 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): 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 a driver is on each shift to ensure outings are available. 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. The home has homely touches to ensure that the personalities of the service users are reflected. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 10 One service user is supported to keep goldfish in their bedroom. Service users were involved in preparing lunch and dessert. As noted in the previous inspection reports service users have to contribute financially to any holidays as they are not included in the basic contract price. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 11 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 A safe medication system is not in place. Service users personal needs are met. The dignity of service users could be better observed. EVIDENCE: One service user has recovered from pressure wounds and appears more settled and content. This is due to staff working hard to meet their needs. An immediate requirement has been made as there has been little improvement regarding safe practice of medication. Medication temperatures must be recorded to reflect appropriate storage. Medication had not been in stock (as found at the previous inspection) and therefore not given. Medication records had not been transferred onto a new Medication Administration Record Sheet and had been given and not signed for and not given according to the amount remaining. PRN (as required) medication must be stored in the original container to reflect pharmacy instructions, as some is currently not stored in this manner. A regular internal audit system review is advised to address these issues. One service user had a large sign next to their bed to instruct staff. This must be placed more discretely to ensure dignity is observed. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 12 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 & 23 There is a clear and effective complaints policy. EVIDENCE: The complaints policy is in a pictorial format to ensure service users can use and understand it. The contact details of the Commission have been 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. A recommendation has been made. Finances are securely stored and on checking were found to be accurately recorded. A recommendation has been made to evidence checks with two signatures and to audit more frequently. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 13 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): 24,26,27,29 & 30 The premises are suitable for the needs of the service users. Flooring and furnishings require deep cleaning. 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 new hoist has been purchased as a replacement. 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. New carpets have been fitted in the hallway. A requirement has been made for all carpets to be professionally cleaned as they are stained and dirty which daily hoovering cannot address. The same is true of the lounge furniture. There are some maintenance issues which have been reported. Staff reported that repairs are generally carried out in an acceptable timescale. A requirement is made later in the report. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 14 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): 32,33,34,35 & 36 Service users are not safeguarded by the Company’s recruitment process. Training is in place to assist staff to meet service users’ requirements. EVIDENCE: There are currently some vacancies within the home which permanent and bank staff are covering with the use of some agency staff. A requirement has been made regarding personnel records. Inadequate employment information was disclosed on an application form and references did not correspond with the information given. This must be rectified and not happen in future. A copy of individual contracts would illustrate the capacity in which the staff member is employed. A requirement has been made. 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 DS0000019613.V264289.R01.S.doc Version 5.0 Page 15 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, 41, 42 & 43 EVIDENCE: A requirement has been made for the manager to submit their application to register with the Commission for Social Care Inspection. She is currently working towards the Registered Manager’s Award. 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. Requirements have been made regarding health and safety. The magnetic closers on the lounge fire doors are broken. 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. The water temperature in one of the bathrooms is too low (25ºC) and an immediate requirement has been made. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 16 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 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbrook House Score 2 3 1 X Standard No 37 38 39 40 41 42 43 Score 1 3 3 X X 2 3 DS0000019613.V264289.R01.S.doc Version 5.0 Page 17 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 YA18 Regulation 12(4)(a) Requirement The dignity of service users must be observed. Signs giving instructions to staff must be displayed discreetly. Records must demonstrate that medication is stored at the appropriate temperature. 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 instructions must be signed (preferably by a G.P.) THIS IMMEDIATE REQUIREMENT REMAINS UNMET FORM THE PREVIOUS INSPECTION. Timescale for action 30/11/05 2 YA20 13(2) 11/11/05 Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 18 3 YA30 4 YA34 5 YA37 6 YA43 Medication must be regularly audited to ensure correct procedure is followed. 23(2)(d) Stained soft furnishings (lounge) and carpets (throughout the home) must be cleaned preferably by professionals. 17(2)&19 Application forms must reflect a comprehensive employment history. References must correspond to the employment history. Adequate checks must be conducted to safeguard service users. CSA para The manager must submit a 11 Registration Application to the Commission for Social Care Inspection. 12(1)(a) Hot water must be delivered & 13(4)(c) close to 43ºC as it is currently is too low at 25ºC. THIS IS AN IMMEDIATE 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 they are safe. THIS ISSUE WAS RAISED AT THE PREVIOUS INSPECTION AND REMAINS UNMET. 12/12/05 16/11/05 16/11/05 11/11/05 Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 19 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 Refer to Standard YA14 YA23 Good Practice Recommendations Holidays should be incorporated into the basisc contract price. This recommendation was made at the previous inspections. Two signatures are recommended to evidence staff checking service users’ monies. It is recommended that this be audited more regularly than currently. Westbrook House DS0000019613.V264289.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 DS0000019613.V264289.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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