Inspection on 21/08/06 for Westbury Court

This inspection was carried out on 21st August 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westbury Court 30/07/07

Westbury Court 21/11/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westbury Court Westbury Court Gardens Westbury-on-severn Glos GL14 1PD Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 21st August 2006 08.45 X10015.doc Version 1.40 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 Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbury Court Address Westbury Court Gardens Westbury-on-severn Glos GL14 1PD 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) 01452 760429 01452 760355 manager.westbury@osjctglos.co.uk The Orders of St John Care Trust To be appointed Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include one named service user under the age of 65 years. This condition to be removed once the service user reaches 65 years or is no longer accommodated in the home. 21st November 2005 Date of last inspection Brief Description of the Service: Westbury Court is a purpose built care home located in the village of Westbury on Severn, and is approximately 10 miles from the centre of Gloucester. It is registered to provide personal and nursing care for 42 older people, and also has two designated respite accommodation rooms. The home is managed by the Orders of St John Care Trust. A registered general nurse is on duty twenty-four hours a day. All health care services are accessible from community resources, and residents can register with one of the local General Practitioners. The home provides level access throughout, and residents are accommodated on two floors; a staircase and shaft lift provide access to the first floor. Accommodation is provided in single rooms, though a small number of rooms have an interconnecting door if wanted for couples. Each room has its own wash hand basin, and three rooms provide en-suite facilities. Bathrooms and toilet areas are numerous and easily accessible, and are spacious and fully equipped to meet the needs of less able residents. Communal areas include a smaller lounge on both floors and a large lounge/dining room and small conservatory on the ground floor. A pleasantly situated garden is at the rear of the home, and is easily accessible to the residents. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Westbury Court range from £337.15 to £637.00 per week. Hairdressing, Chiropody and Holistic Therapies are charged as extra individual costs. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over two days in August 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of four residents being closely looked at in particular. The management of residents’ medications was inspected. A number of residents were spoken to directly in order to gauge their views and experiences of the services and care provided at Westbury Court. Some staff were also interviewed. Survey forms were issued to a number of residents, visitors and staff to complete and return to CSCI if they wished. 100 of resident surveys, 10 of relative surveys and 20 of staff surveys were returned; some of their comments are featured in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. What the service does well: Westbury Court provides a well-maintained, safe and clean environment for the residents living here. The surrounding grounds are beautifully maintained, and provide pleasant gardens for the residents. Residents are admitted to the home on the basis of an assessment, so that they can be assured the home can meet their individual needs. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 6 The home has a positive working relationship with local doctors, and ensures that each resident is afforded good access to all community health care services, with appropriate medical interventions when required, to assist in meeting their health needs. Residents and visitors speak positively about the care at Westbury Court, with residents themselves generally very satisfied with the way in which they are looked after here. Relatives say that they feel welcome in the home, that they are consulted and kept informed appropriately by the staff. There is a good standard of food served, and residents confirm that they enjoy their meals very much. Residents have the chance to exercise choice with their food, as they are in other areas of their life as well. Though the home has a robust procedure for addressing any complaints or concerns, they should make the procedure more accessible to visitors and all in the home. The standard of care, services and facilities is regularly reviewed as part of good quality monitoring systems. There are appropriate training and management systems here that will protect the rights and welfare of the vulnerable residents. Staff are trained in adult protection issues, and residents can safely place money and valuables with the home for safe-keeping. Staff have good training opportunities, and are offered the chance to gain a professional qualification at National Vocational standard. New staff are fully supervised. What has improved since the last inspection? The standard of care plan documentation is better, being more comprehensively recorded, and providing clearer direction as to the needs and care of each individual. The home now has contract for the collection and disposal of waste medications, in order that it can comply with new regulations regarding such items. There has been some more staff recruitment recently, which in turn has managed to reduce the amount of agency staff usage in the home. Some areas of the home have been improved, with ongoing redecoration, provision of some new carpets and conservatory blinds, and some refurbishment work to the passenger lift. The outgoing temporary manager has done well to provide a degree of stability and leadership to Westbury Court over the past year, but the appointment of a Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 7 new and permanent manager should provide greater continuity and assurances for all. 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. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to information about the home to assist them in making their choice about moving there, although some work to further improve this remains incomplete at this time. Assessments are carried out on all prospective residents, so that they can be assured prior to admission that the home can meet their needs. EVIDENCE: Written survey responses from residents or their relatives confirmed that they had had access to information about the home prior to their admission. The review and implementation of updated information brochures (Service User Guides) has been slow since The Orders of St John Care Trust has taken over the management of the home. An updated copy has not been supplied to the CSCI as was required, within the agreed timescale. However, assurances have been given that work is near completion on this exercise, and the new brochures are being introduced. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 10 Copies of assessments carried out on three recently admitted residents were inspected. These had been conducted in hospital or at the person’s home address before their admission to the home was agreed; a copy of a letter was on file for one of them, in which it was confirmed that the home would be able to meet their needs. Appropriate care and health information from other health care professionals was also on file, as were copies of the placing authority assessments and care plans where applicable. Westbury Court does not provide intermediate care. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the care planning system mean that staff have better information available to care for the residents’ health and personal needs; however focus on further improvement should close any remaining gaps in this regard. The systems for the administration of medications are generally satisfactory and provide appropriate safeguards for residents, but only if consistently applied. In the main care is offered in such a way as to meet residents’ needs in respect of their privacy and dignity. EVIDENCE: There is a definite improvement in the standard of the care plan documentation at Westbury Court since the last inspection. Apart from an isolated few that have slightly less detailed recording and review outcomes, they generally contain satisfactory planning and direction for staff to deliver individuals’ care in accordance with their assessed needs. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 12 Four care plans were selected as part of a case tracking exercise. A personal profile was recorded for each resident. Each had been regularly reviewed and updated as necessary. They were personalised, and were reflective of individuals’ choices and levels of independence. Care plans were directly linked to assessments, including risk assessments where applicable; these included moving and handling, falls, and pressure sore risk assessments. Nutritional risk assessments had not been recorded, though each resident is regularly weighed, and case tracking showed that dietary supplements had been prescribed in one case where it had been needed for the health and welfare of the resident; the manager resolved to introduce a recording tool to assess residents’ risks nutritionally. Appropriate measures and equipment were in place to support residents as identified on assessment, such as adjustable beds, pressure relieving mattresses and cushions, hoisting and mobility equipment. Wound care plans were recorded where applicable. Recording confirmed that regular medical reviews are carried out on each resident, and that they have access to all health care services as required. Care was being delivered in accordance with the care plans, and when interviewed, staff were able to demonstrate their understanding and awareness of individuals’ needs and their planned care. In two of the cases there was evidence of some mental health needs on assessment. Recorded care planning in these areas was not adequately robust, and did not incorporate the interventions of the psychiatric services. Residents are supported to manage their own medications if they wish and are able to, and this is done on the basis of a recorded risk assessment, otherwise the nursing staff in the home manage them. A new and improved system for ordering supplies has been introduced, and medications are stocked and stored safely and appropriately. Supplies are boxed and bottled by the local surgery’s pharmacy, and staff date each item on opening so that they cannot be used beyond their expiry date. However, in two bedrooms there was a pot of medicinal cream that had been well used; neither had a pharmacy label attached, and neither had been dated, making it difficult to know that the expiry date of the opened cream had not been exceeded. Associated records are satisfactorily maintained, though there are very isolated signature omissions on some charts; senior staff do not ignore these omissions, and efforts are made to rectify them. The staff legibly handwrite medication administration charts. Two nurses sign the entries, as is good practice, though there are some that are only signed by one. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 13 In order to comply with the Special Waste Regulations for the disposal of unused medications, the home now has an agreement with a licensed contractor for collection and disposal. There are accessible medication guidelines and policies for staff to follow. Nurses responsible for medication management have not had updated training recently. Care was being delivered in the privacy of individuals’ bedrooms or in bathrooms. It was necessary to hoist one of the residents in a communal room, and the staff involved explained what was taking place, and made some effort, though not entirely successful, to ensure the person’s dignity by covering her with a small blanket. Staff were generally heard approaching residents in a friendly and polite manner. Residents themselves seemed satisfied with their care and the way in which it was delivered. A number of residents said that staff were caring and kind, and that they felt respected by them in terms of their privacy and choices. One lady, who had been poorly the previous night, said that the staff had been particularly kind and helpful to her. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s limited effort to provide social activities for residents has not sufficiently catered for diversity of need and interest. Visiting arrangements are such that residents can keep close contact with their families and friends, with respect shown towards individual choices. Though the timing of some meals does not consistently meet everyone’s needs, residents’ dietary requirements are well catered for, with a selection of food available that meets individuals’ tastes and choices. EVIDENCE: Survey responses from residents and their relatives indicated that some of them feel bored on occasions. One survey said that there is little mental stimulation here, whilst two others said that access to activities was very limited due to their sight problems. Other resident responses indicated that they viewed the provision of social activities in a rather more positive light. There was no programme of activities available, though clearly entertainment has been provided on occasions, with some residents actually being taken out as well. Some details displayed on a notice board advertised a visiting hairdresser, chiropodist, priest and holistic therapist. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 15 Minutes of resident meetings demonstrate that staff have consulted with residents about their ideas for social activities, but progress to implement a programme which can meet peoples’ diverse needs is slow. There are plans however to employ a part time activities coordinator, who can devote more time to developing a programme for all residents in the future. The small number of written survey responses from relatives confirmed that they feel welcome at Westbury Court, and that they are consulted and kept properly informed by staff in the home. One survey said that the home provided an excellent service. One survey indicated that they were able to spend as much time in the home with their relative as they wished, and could frequently take meals with them. Residents were observed spending time quietly, some reading, watching television or doing crosswords; some were sitting in small groups, socialising independently. Some were moving about the home according to their choice and preferences, but there were a large number of residents who are rather more dependent on the staff for all their needs. There is at least one resident who has elected to manage her own affairs independently; there are others who have the necessary arrangements in place to assist them with their affairs, as they require more support in this regard. One resident has made particular arrangements in advance, so that his wishes are known and respected by those involved in his care. Evidence of residents’ freedom of choice was seen in other areas, such as the personal influences noted in individual bedrooms, and with different meals and ways of spending time. Staff were also heard offering choices to different people in a number of areas. Personal choices were in evidence during the service of the well-presented and nutritious lunch. There were at least three different meals provided, with a selection of puddings as well. A list of residents’ choices for lunch had been compiled in advance, and provided to the cook for her reference. Written survey responses were overwhelmingly positive about the good quality of the food, though one said that they would like to see a broader choice. The kitchen was orderly, though very busy, and record keeping regarding temperature monitoring and cleaning schedules was in order. The cook was knowledgeable about the different dietary requirements of the residents, and had records of each individual’s requirements, likes and dislikes. As reported on previous occasions, the breakfast meal is served far too late for some people; at the very least there were three residents having their breakfast between 11am and 11.30am, just over an hour in advance of their lunch. One resident said this was not unusual, and that she would prefer to have it earlier. The new manager was equally concerned about these circumstances, and is meeting with staff urgently as a consequence to find ways of resolving it, so that each resident’s needs might be met more satisfactorily. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for addressing complaints enable residents and their families to feel assured that their views would be listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: The written procedure for residents or visitors to raise complaints or concerns is no longer readily accessible in the home; a copy is contained within the Statement of Purpose folder in the hall, but it was previously clearly displayed for peoples’ reference. The home has a system for keeping records in relation to any complaints received, with appropriate auditing arrangements in place; however, records pertaining to two complaints could not be located during this visit. Resident and visitor survey responses confirmed their awareness of how to make a complaint and of who to speak to if they had any concerns. They indicated their confidence in the staff to help them with any concerns they might have. One person said that staff could be ‘a bit slow to respond to minor requests’. The home has written policies and procedures for the protection of the vulnerable residents. Staff have received training in the recognition and handling of potential abusive practices. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 17 A copy of the Department of Health’s POVA (Protection of Vulnerable Adults) Guidance and the ‘No Secrets’ document is accessible to staff. Staff have signed to acknowledge their understanding of the home’s policy regarding the non-acceptance of gifts and gratuities offered to them. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Westbury Court generally provides residents with a comfortable and safe place to live. The home is clean, with appropriate and full observations regarding the control of infection. EVIDENCE: Some of the residents’ rooms are quite small at Westbury Court, but despite that the home provides comfortable and homely accommodation for the residents. The environment is generally safe, well maintained and decorated. Maintenance personnel are employed, and cyclical maintenance records are kept. There is an ongoing redecoration programme, and a number of bedrooms have been done; carpets have been replaced as necessary. At least three bedroom carpets were showing signs of wear and tear however, and these were pointed out to the manager for prioritising. There are also a few items of bedroom Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 19 furniture, such as some wardrobes and drawer cabinets, which are beginning to show signs of their age and long usage. Some of the commode chairs appear old, though are evidently clean and serviceable. New window blinds have been fitted in the conservatory. There has been some refurbishment work to the passenger lift. The surrounding external grounds are extremely attractive, and have been beautifully planted for the summer. The rear garden provides a safely enclosed and pretty seating area that residents can enjoy. There are good infection control measures here, with liquid soap, paper hand towels, hand sanitising gels, gloves and aprons widely available. Clinical waste is safely managed, with a contract in place for safe disposal. All areas of the home are clean and fresh, and comments from residents and visitors indicate good levels of satisfaction with the standards of cleanliness maintained here, and with the good quality of the laundry. One written survey response said that the home was ‘well run and spotless’. The laundry room was tidy and well organised, and washing machines are capable of disinfecting any foul laundry. The laundry assistant was conversant in the proper infection control procedures for the laundry. A new ventilation duct has been fitted in the laundry room since the last inspection visit. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing provision is just adequate to meet the needs of the residents currently living in the home. Recruitment procedures will ensure suitable staff are employed for the protection of residents, but only when consistently applied. The arrangements for the induction and training of staff are good, with the staff able to learn the skills necessary for their role. EVIDENCE: A staff rota is maintained, which allows for one registered nurse to be on duty at all times, with eight care staff in the morning, six or seven in the afternoon and evening, and two overnight. The newly appointed manager works in a supernumerary capacity, and the deputy manager now has four hours each week when she too can work in a supernumerary capacity. An ancillary team of cleaning, laundry, catering, maintenance and administration staff ably supports the care and nursing team. There has been some significant recruitment of relief staff recently, which is reducing the amount of agency staff usage here. The resident call bell system was periodically sounding for prolonged spells, before a member of staff responded; staff were busy trying to meet the needs of the residents, but were slightly reduced in capacity due to one absentee and with new staff under instruction on the team. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 21 As seen on previous occasions, the breakfast meal was served very late into the morning for some residents, due to staff adhering to more task oriented ways of working. The newly appointed manager is already considering ways to address this team issue, in order to meet the needs of the residents more satisfactorily in this regard. Residents’ and visitors’ responses all indicate that the staff are caring and helpful, although a small number expressed a concern about what they viewed as low numbers of staff on occasions, particularly at weekends. Despite this, rotas showed no variation in the numbers of care staff at weekends; it was reported that there are occasions when last minute staff sickness cannot be covered however. There are currently nine care staff who are NVQ (National Vocational Qualification) qualified to at least level 2, with one of these being at level 3. Three care staff are on the NVQ level 2 training programme at this time, whilst two others are doing their level 3 award. Although the home has not yet achieved the recommended target of at least 50 of qualified care staff, they are making excellent progress towards achieving this. Five staff files were chosen for inspection, on the basis of their recruitment to the home since the last inspection. Each record contained application forms. Employment history in two cases appeared to be incomplete; there was no evidence that any gaps had been explored during either interview. Full and complete evidence of the required pre-employment checks was seen in each of the files, including medical checks, proof of identity, two written references, POVA checks and CRB clearances. Copies of job offers and work contracts were contained in the files, and there was evidence of ‘return to work’ interviews following any absences due to ill health. A training events programme is made available from The Orders of St John Care Trust Training Manager. The home has a designated training coordinator, and meticulously kept training records show that staff have attended a variety of mandatory and optional training in issues relevant to their caring role. New staff attend formal induction training, comprising of two days structured learning at a training centre; certificates for new staff were seen in their personal files. Records of in-house induction, more specific to Westbury Court were also seen, which included the name of the supervisor allocated to mentor the new worker for the duration of their induction training. Certificates of training undertaken are given to each person, and carers have been provided with the General Social Care Council Code of Conduct. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the temporary management has provided some reassurances for residents and staff, the permanent arrangements being put into place now should allow for greater continuity for all in the future. The home reviews aspects of its performance through a good programme of self-review and consultations, which includes seeking the views of residents and their relatives. EVIDENCE: Westbury Court has a newly appointed manager, who only started here just before this inspection visit was carried out. The home has not had a registered manager for some time, though temporary management arrangements have been in place. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 23 The incoming manager is a level one registered nurse, who has had at least two years experience in caring for older people in a similar setting. She is required to submit an application to CSCI for her registration, and steps to address this are already underway; she must undertake the NVQ level 4 Registered Manager Award, and has confirmed her intention to commence this as soon as possible. The manager appears to have made a most positive start at Westbury Court already, and is confidently identifying areas of priority for her attention. The home uses a range of quality monitoring systems to help evaluate and improve its services. Annual quality monitoring survey forms have recently been issued to residents and their families, and the completed forms are being sent to the Quality Assurance Manager, who will collate the results and return them to the manager for any action that may be necessary. The latest survey has invited views on the environment, catering, care, social activities, services and visiting arrangements. The home undertakes a six monthly review with each resident, with their relative in attendance if they wish, so that they can offer their views about care, services, facilities and any concerns they may have. Meal monitoring forms are also regularly issued to residents chosen on a random basis, so that they can give feedback on their experiences of the food and drink provided for them in the home. Minutes of a recent resident meeting were seen, and these demonstrated that residents are enabled to have their say in the running of their home. The newly appointed manager has been endeavouring to make herself accessible to residents and their families, and plans to hold an informal meeting soon, so that relatives can discuss any issues with her as the incoming manager. Many residents have placed personal money with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. A random check on a resident’s money against their records proved to be correct, with no discrepancies seen. Residents or their representatives sign to acknowledge transactions in only very isolated cases, with two staff members signing records to witness on behalf of the resident where this is not feasible. There was evidence that health and safety issues are addressed well in this home, with written policies, procedures and risk assessments and provision of necessary equipment. An external assessor has performed a fire safety risk assessment throughout the building, and an action plan to address the risk assessment findings is awaited at this time. Records show that staff have recently received training in fire safety, and that two fire drills have been carried out; this record had been newly started, and did not contain records of training prior to this date. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 24 Ten staff have received training in first aid; the deputy manager has undertaken the more comprehensive 4 day course. First aid equipment is provided in the home. Hot water temperatures are regularly checked for safe levels, and regular Legionella checks on the water supply are also carried out. All necessary safety checks and maintenance of equipment is undertaken in a timely fashion, and meticulous records are kept in these areas. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4(2) 5(2) Requirement The registered person must send the revised copies of the Statement of Purpose and Service User Guide to the CSCI upon completion. This requirement has been repeated from the last inspection. The registered person must ensure that: • A pharmacy label is attached to all prescribed items, and that they are not used beyond their expiry date • Staff sign medication charts to confirm administration of medication. The registered person must ensure that the home provides a social activities programme that will meet residents’ needs. This requirement has been repeated from the last inspection. When recruiting new staff the registered person must ensure that a full employment history DS0000064610.V301442.R01.S.doc Timescale for action 30/09/06 2. OP9 13(2) 30/09/06 3. OP12 16(2.n) 31/10/06 4. OP29 19(1) Schedule 2 (6) 30/09/06 Westbury Court Version 5.2 Page 27 with satisfactory written explanation of reasons for gaps in employment is obtained. 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. Refer to Standard OP9 OP16 OP28 Good Practice Recommendations Two members of staff should sign to witness handwritten entries on medication charts. The written Complaints Procedure should be clearly displayed in the home. A minimum ratio of 50 of care staff qualified to NVQ level 2 should be achieved in the home. Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Westbury Court DS0000064610.V301442.R01.S.doc Version 5.2 Page 29 - 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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