Inspection on 02/09/05 for Westbury Gardens (Residential Suites)

This inspection was carried out on 2nd 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

Westbury Gardens (Residential... 21/03/07

Westbury Gardens (Residential... 24/02/06

Westbury Gardens (Residential... 31/03/05

Westbury Gardens (Residential... 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Westbury Gardens Falcondale Road Westbury On Trym Bristol BS9 3JH Lead Inspector Sam Fox Unannounced 2nd & 5th September 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westbury Gardens Address Falcondale Road Westbury On Trym Bristol BS9 3JH 0117 950 7117 0117 9146665 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) Westbury Care Limited Mrs Rita James Care Home Only 22 Category(ies) of OP Old age registration, with number of places Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 22 persons aged 65 years and over requiring personal care Date of last inspection 31 March 2005 Unannounced Brief Description of the Service: The Westbury Gardens Residential Suites are located within the grounds of Westbury Nursing Home and is operated by the Westbury Care Limited Group. It is registered to provide accomodation for 22 people, over 65 years, who require personal care. The building is a one storey bungalow design and each bedroom has an ensuite facility. It is located a short walk from the village of Westbury-on-Trym, where there are local shops, pubs and other amenities. It is also close to public transport. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the purpose of which was to ensure that the premises are being well maintained and that residents were happy with the service they were receiving. In addition to this the home’s care planning, recruitment and health and safety procedures were inspected. The primary evidence was gained through discussion with residents, 12 of who were consulted with in-depth and consultation with the manager. In addition to this, key records were inspected. What the service does well: What has improved since the last inspection? Seven members of staff have been registered to take their National Vocational Qualifications – this should lead to improvements in the service provided and enable the home to meet the target that 50 of the workforce have relevant training to carry out their duties. Improvements continue to be made to the menus and residents have played an active part in this change. The home has recently appointed a new manager who is well known by residents and staff and who has settled into the role well. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 6 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 Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 8 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 standard(s) 5 The home has an open admissions procedure so residents and their family can be reassured that they can find out all the information they need to make a considered decision to move there. EVIDENCE: The majority of these standards were not assessed and will be a focus of the next visit. There was a copy of the home’s Statement of Purpose, inspection report and information about the CSCI in the home’s entrance. This is good practice and enables family and visitors to know what they can expect from the service. A number of residents said that their families had found out about the home and looked around for them. Many of them moved to the home straight from hospital and said that they had not felt well enough to have a look round themselves. One resident said she visited the home first prior to making a decision to move there. It was evident that they all felt they had the time and opportunity to find out about the home prior to making a decision to move there. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 9 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 standard(s) 7,8,10,11 Care plans need to be improved so that the home can demonstrate they are providing an individualised service. Residents can be confident that staff will treat them respectfully and uphold their privacy. EVIDENCE: Each resident has a personal file that includes information about them, including past history, daily routines, nutritional assessments and care plans. There was some good detail within these. It was noted, however, that some records were incomplete and there was insufficient detail to establish exactly what staff were expected to do. In addition to this some care plans were being reviewed more regularly than others. Action needs to be taken by the manager to consolidate these and ensure that they are more consistent. In addition to this she should ensure that plans are discussed with, and agreed to, by residents. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 10 Records evidenced that residents are supported to see the relevant health care professionals and to attend regular checkups with, for example, the opticians. It was noted that some people are weighed when there is an identifiable health issue. All residents consulted with said they could see a Doctor when they wished and they were pleased with the support they received from the home to meet their health care needs. There were assessments available in relation to the likelihood of developing pressure sores. All residents spoke highly of the staff team and what they did for them. They said staff were always friendly and respectful. Observation of interaction at the time of the visit confirmed this. Residents were spoken with in the term of address that they preferred and staff knocked on doors prior to entering. It was commented that sometimes residents overhear what staff are saying in the small kitchen, which is in close proximity to the dining room. Staff should be reminded to be discreet in these areas. On some personal files it was not clear what residents wishes were in the event of their death. The manager should try and sensitively find out this information so that their death is handled with dignity and that their wishes are observed. Residents said that they were kept informed if someone was ill or had died. The home is small and residents clearly feel part of a community, it is important that such information is conveyed to them with sensitivity and without breaching confidentiality. It was apparent that staff are managing this balance well. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 11 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 standard(s) 12,13,15 Staff foster a relaxed atmosphere which means residents can pursue lifestyles suited to their own preferences. EVIDENCE: All residents consulted with said that they were able to dictate their own routines and that there were no unnecessary rules. One resident said, “you can do as you like according to how you feel”. They confirmed that they were able to go to bed and get up when they pleased and go out when they wished. One resident said she always had breakfast in her bedroom so that she could start the day off slowly. A number of residents receive regular visits from family and friends and this was observed at the time of the inspection. Formal activities are organised at periodic intervals, including armchair exercises and outside entertainers. A number of residents said that they chose not to join in and were pleased that they had the choice. In addition to this there are trips out in the mini bus. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 12 It was apparent that there have been issues with the menus and some residents said they had been dissatisfied with the quality of some of the dishes. They were pleased, however, because they had met with the chef in a residents meeting and agreements had been made about how to improve the situation. This was further confirmed through minutes of residents meetings that detailed discussions and agreements that had been made. This is good practice and evidences that the home is willing to listen to and act upon residents concerns. Opportunity was taken to join residents with their lunchtime meal. This was served in a sensitive and unhurried manner. It appeared to be enjoyed by all residents who view mealtimes as a social occasion. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 13 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 standard(s) 16,18 Staff are open and sensitive to residents wishes – they can therefore be confident that they will be listened to. EVIDENCE: The complaints procedure is clearly highlighted on the home’s notice board, alongside information leaflets about the CSCI. This includes timescales for action and meets with requirements of the legislation. All residents spoke openly about the service they received and it was apparent that they felt confident to say what they felt. They all expressed confidence in the staff and manager – to whom they said they would raise concerns if they had any. There have been no complaints received by the CSCI. A number of residents mentioned that they attend a two monthly residents’ meeting and it was apparent that they were pleased to be given the opportunity to comment upon the service they receive. There were was an easy to read protection of vulnerable adults procedure clearly displayed in the office. Staff are in the process of receiving training about abuse – this meets with requirements the legislation. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21,22,23,24,25 & 26 The home is well maintained so residents can be re-assured that they will benefit from living in a safe, clean and homely environment. EVIDENCE: Westbury Gardens is purpose built on the site of a nursing home operated by the same organisation. As such it is fully accessible, there are wide corridors and doorframes and each room has an ensuite facility. The home is located close to local shops and amenities. Opportunity was taken to inspect all the bedrooms. These were found to be personalised and to reflect individual tastes. A number of residents said how pleased they were that they could bring in some of their own furniture to make it feel more like home. They also confirmed that they could lock their bedroom doors if they wished (although most chose not to do so). Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 15 Each bedroom has patio doors leading to a small porch area. This gave a number of residents great pleasure and the gardens they led on to were well maintained. It was observed that a number of residents have their own telephone (which they pay for). There was also a pay phone located in an accessible place. One identified room had stained and peeling paintwork. This is in need of redecoration. All areas of the home were found to be cleaned to a good standard and there were no unpleasant smells. All residents consulted with said they were pleased with the hygiene and said that staff worked hard to maintain it. Radiators had low surface temperatures and emergency lighting is provided throughout the home. All bedrooms were well lit and lighting was domestic in character. It was understood that hot water temperature are monitored – these records were not seen at the time of this visit. There are a number of aids and adaptations throughout the premises. The corridors are wide and there are a number grab rails and raised toilet seats. It was noted that the home is equipped with a small domestic style washing machine and dryer. These are located in a cupboard which backs onto a corridor. Whilst this is not an ideal solution this saves staff from sending clothes to the main nursing home. The washing machine does not have a sluicing facility so the home would need to find alternative arrangements for soiled linen. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 The recruitment procedure needs to be more robust so that it is in place for the protection of vulnerable adults. EVIDENCE: At the time of this inspection there were 19 people in residence. Rotas indicated that there are two care assistants on duty throughout the day (this increases up to three for a limited period over supper time), one of which is the manager twice a week. In addition to this the home employs a kitchen assistant and a housekeeper. There are two waking night staff. Residents did not complain about staffing levels or comment that they had to wait a long time for assistance. In addition to this all those residents currently accommodated are relatively independent. These are, however, minimum staffing levels and do not provide much scope for flexibility, for example, in times of emergency or illness. The home must review staffing levels and these should increase if levels of dependence increase. This will continue to be a focus of forthcoming inspections. The manager explained that seven care assistants have recently started their National Vocational Qualification (Level 2). When completed these will enable the home to demonstrate that there is a minimum ratio of 50 trained staff members. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 17 Opportunity was taken to view two personal files. These were found to include contracts, terms and conditions, medical questionnaires and evidence that the manager carries out appraisals of work practice. The recruitment procedure comprises of the use of completed application forms, formal interviews and the obtaining of references and police checks. It was noted that there was only one reference for the newest member of staff and that this was brief. The home must ensure that two written references are obtained prior to employment, one of which should be from their current or most recent employer. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,38 The home is well managed so residents can expect their health, safety and welfare to be effectively maintained. EVIDENCE: The manager is well respected by residents who expressed confidence in her ability to manage the home. She is to begin her Registered Managers Award in October and this should help her to further develop her skills. She displayed an awareness of her responsibilities as registered manager under the Care Standards Act. There were detailed minutes of staff meetings that are held at regular intervals. These provide a useful more formal forum through which staff can influence the routines within the home. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 19 The fire logbook evidenced that the home makes the appropriate tests and checks of the system and that staff receive regular re fresher training. It was noted that many bedroom doors were propped open, it was understood the fire brigade have advised the home that they can do this during the day (as long as the obstruction can be easily pushed aside) but must ensure the doors are closed at night. Some residents like to have their bedroom doors open at night and fire “dorguards” can be purchased which prop open doors but release them when the fire alarm sounds. Residents should be given this option. If the organisation intends that residents should pay for this then it should be clearly recorded in the home’s statement of purpose and \or service user guide. Progress on this will be the focus of the next visit. There was an up to date insurance certificate. There were health and safety risk assessments available although these were not looked at in detail during the time of this visit. In addition to this the organisation has a number of health and safety policies. Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.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 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 x x 3 Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.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. 2. 3. 4. 5. Standard 24 11 27 7 28 Regulation 23 (2)(d) 12 (2) 18 (1)(a) 15 18(1)(a) Requirement Ensure bedroom is decorated to a suitable standard Ensure that residents wishes in event of their death are clealry recorded Ensure there is an ongoing review of staffing levels Further develop care plans Ensure that two written references are obtained at all times for new employees Timescale for action 30th November 2005 30th November 2005 30th October 30th November 2005 30th October 2005 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 Good Practice Recommendations Westbury Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.doc Version 1.40 Page 22 Commission for Social Care Inspection 300 Aztec West Almondsbury Bristol BS32 4RG 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 Gardens D56_D05_S26642_WestburyGardens_V246396_310805_Stage4.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. 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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