Inspection on 24/02/06 for Westbury Gardens (Residential Suites)

This inspection was carried out on 24th February 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 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... 02/09/05

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 (Residential Suites) Falcondale Road Westbury On Trym Bristol BS9 3JH Lead Inspector Sam Fox Unannounced Inspection 24th February 2006 08:30 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 Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 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 Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westbury Gardens (Residential Suites) Address Falcondale Road Westbury On Trym Bristol BS9 3JH 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) 0117 950 7117 0117 9146665 Westbury Care Limited Mrs Rita James Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 22 persons aged 65 years and over requiring personal care 2nd September 2005 Date of last inspection 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 accommodation for 22 people, over 65 years, who require personal care. The building is a one-storey bungalow design and each bedroom has an en suite 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. The home is now managed by the registered manager of Westbury Nursing Home, which is located on the same site. A new certificate will be sent to reflect this in the near future Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 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 check on residents’ welfare and on progress made in relation to requirements and recommendations made at the last visit. Another focus was the home’s recruitment, supervision and training programmes. Evidence was gathered through discussion with staff and residents. In addition to this the premises was inspected and key records were examined. Opportunity was also taken to join residents with their lunchtime meal. Not all standards were inspected during the visit and this report should be read in conjunction with others so a fuller picture of the home can be gained. What the service does well: What has improved since the last inspection? All requirements made at the last inspection have been met. Care planning systems have improved, including detail about daily routines – this means residents can be more re-assured that they will receive help that is tailored to their preferences. The recruitment procedure is more robust, with the relevant checks and references taken up prior to offering employment. This means the system serves to protect vulnerable adults. Residents’ wishes in the event of there are now fully recorded. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 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 (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,5 There is an effective admissions procedure in place so residents can be reassured the home will have the skills and resources to meet their needs. EVIDENCE: Westbury Gardens has a statement of purpose, which is located in the foyer of the home. This includes a description of the facilities and services to be offered and the complaints procedure. This meets with requirements of the legislation. It is, however, in need of review as some of the information is out of date. The home carries out a full assessment of all new residents prior to them moving in and there were detailed records to evidence this. This means that the manager and staff can be more confident that they will be able to meet individual needs. All residents are issued with a contract, which they sign their agreement to. This details some of the conditions of residence as well as arrangements in place for insurance and data protection. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 9 All residents spoken with said that they either looked around the home themselves before moving in, or their relatives did this on their behalf. All said they felt they had enough information to make a considered decision about moving there. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 10 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): 7,8,9,10,11 Residents can be re-assured that their health care needs will be met. Care planning systems have been improved so the service is more tailored to individual preferences. EVIDENCE: Opportunity was taken to view three personal files. These contained an assessment of needs, risk assessments and care plans. The details in these have improved since the last inspection and the senior staff team have worked hard to ensure that they are more up to date and tailored to individual preferences. Residents have also been encouraged to sign their agreement to these. This is good practice. Staff review care plans on a monthly basis and also contribute to daily records. The use of language in some of these could be misinterpreted and this should be reviewed. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 11 Records provided evidence that residents continue to be supported to see the relevant health care professionals, including specialists. Residents confirmed that they could see a GP on request and were pleased with the support they received for maintaining their health. They also said that an optician visits regularly as well as a chiropodist. The home operates a monitored dosage system for the administration of medication that is supplied at regular intervals by the local pharmacist. Records held were found to be well maintained and generally met with the requirements of the legislation. There was, however, one instance when tablets were signed for as given when in fact they had not been. The home has recently had an inspection from their pharmacist who issued a number of recommendations. These have all been actioned by the home and included the need to date any opened medication. The home holds some controlled drugs – these were appropriately stored and signed for. As an additional mark of good practice there was information about how each resident liked to take their medication. All personal files included residents’ wishes in the event of their death. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 12 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): 12,13,15 Residents are supported to dictate their own daily routines and to maintain links with family and friends. EVIDENCE: Each personal file contained preferred daily routines and the detail in these has improved since the last inspection. These provide a good picture of individual needs and indicate that residents can dictate their own daily routines. All residents spoken with said the staff were relaxed and that there were no unnecessary rules within the home. They said they could generally do as they pleased, could get up and go to bed when they wanted and have meals in their rooms. There were many relatives and friends observed visiting the home at the time of this visit and it was apparent that there are no restrictions on this. There are some formal activities, including two monthly visits from outside entertainers. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 13 Most residents were satisfied with the quality and quantity of the food provided although this has continued to be the source of much discussion during residents meetings. Opportunity was taken to join residents with their lunchtime meal. This was served on an unhurried and sensitive manner and was well presented. All residents have a main choice. Menus provided evidence that resident’s benefit from a wide variety of nutritious meals and that any medical and dietary needs are catered for. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 14 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 Residents can expect to be listened to and protected from abuse. EVIDENCE: The organisation has a complaints procedure which was clearly displayed in the home. Alongside the statement of purpose and previous inspection reports. This includes timescales for action and references to the CSCI to whom concerns can also be raised. The home has not received any complaints, nor has the CSCI. Residents spoke freely about what it was like to live at the home and they did not appear to be afraid to speak their minds. They said they would talk with the deputy or manager if they had any concerns. In addition to the above staff confirmed that they had protection of vulnerable adults training and said they would report any bad practice. There is a procedure in place for this which identifies key people who should be contacted There have been no allegations of abuse. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 15 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): 19,20,21,22,23,24,25, 26 Residents’ benefit from living in a comfortable, well maintained, 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. The community facilities compromise of a dining room, which is connected to a bright and airy lounge. These areas are comfortably furnished and homely in appearance. There is however, no room for residents to meet their relatives in private (other than their bedroom) or for reviews to be held. These can sometimes present difficulties in terms of confidentiality. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 16 Bedrooms continue to be personalised and reflect individual tastes. Residents said they were able to bring small times of furniture from home which was a great source of comfort to them. All areas of the home continue to be cleaned to a good standard and residents commented on this during the inspection. There are infection control policies in place and the housekeeper confirmed that she had received training. The heating has recently been serviced. There has been an issue in one part of the home, which is not always heated to residents’ satisfaction. This is a fault with the system which is proving difficult to rectify. As a consequence one resident is using a stand-alone radiator bought in by a relative. The home must ensure, via the risk assessment process, that this has a low surface temperature and is located in a safe position. Hot water temperatures are tested at regular intervals. Emergency lighting is provided throughout the home and other lighting in bedrooms is domestic in character. The washing machine is domestic in size and located in a small cupboard. Staff confirmed, however, that soiled linen and bedding gets sent to the nursing home on site where there are more suitable facilities. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 17 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 Recruitment procedures are robust and protect vulnerable adults EVIDENCE: Staffing levels continue to be kept at minimum levels in that there are two staff on duty at all times for nineteen residents accommodated. In addition to this there is a housekeeper and an additional member of staff who works in the kitchen at peak times and serves tea. Those residents currently accommodated are relatively independent and require limited assistance with their personal care. If levels of independence were to increase then staffing levels would need to increase to reflect this. During this visit some residents did mention that they thought the home was short staffed and that this presented problems if staff were off sick. One member of staff said this had been a problem but on the day of the visit they were inducting two new staff which had led to an improvement. Opportunity was taken to view two staff files (one of which was for the newest employee). These contained completed application forms, two references and police checks. Procedures in place have improved in this respect and the files were well organised. All staff are issued with a contract, job description and terms and conditions. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 18 All those staff currently employed have either achieved their national vocational qualifications or are in the process of doing it. This is good practice. In addition to this other training is organised, including, for example, mental health and dementia. All those staff spoken with were satisfied with the opportunities they had to train. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 19 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): 32,36,38 The home is well run and residents’ health and safety is protected. EVIDENCE: A new manager is recently been appointed who manages the nursing home on site. The home also employs two deputies who take responsibility for a lot of the record keeping, care plans and staff supervision. At present this arrangement is working well. Staff confirmed that they received regular supervision and this was evidenced through records. They spoke positively about working in the home and clearly enjoyed their jobs. The last recorded staff meeting was in November and it was noted that another one has been organised for January. It is recommended that these be held more frequently. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 20 The home has a number of health and safety risk assessments covering generic tasks. These are in need of review. Training record indicated that not all staff have had their manual handling updates. Apart from this, however, there is a rolling programme of statutory training in place. All portable electrical appliances have been tested. The home carries out weekly health and safety audits. Those seen were up to date and provide a useful tool for monitoring safety. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 21 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 2 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x x 3 x 2 Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP1 OP9 OP38 OP38 OP25 Regulation 6 13(2) 13 13(5) 13 (4)(b) Requirement Review Statement of Purpose Maintain accurate records of any medication administered. Review health and safety risk assessments. Ensure all staff have manual handling training. Risk assess use of stand alone radiator to ensure it is safe Timescale for action 30/04/06 24/02/06 30/03/06 30/04/06 05/03/06 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 OP36 OP7 Good Practice Recommendations Hold staff meetings more frequently Review use of language in reports. Westbury Gardens (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos 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 (Residential Suites) DS0000026642.V283630.R01.S.doc Version 5.1 Page 24 - 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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