Inspection on 08/11/05 for Westbury House Nursing Home

This inspection was carried out on 8th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbury House Nursing Home 23/05/07

Westbury House Nursing Home 10/01/07

Westbury House Nursing Home 12/07/05

Westbury House Nursing Home 04/01/05

Westbury House Nursing Home 13/07/04

Similar services:

Flint House

The Cotswold Home

Fairways

Treloar College

Rush Court

The Maypole Nursing Centre

Fir Tree Lodge

Chilmington House

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

CARE HOME ADULTS 18-65 Westbury House Nursing Home West Meon Nr Petersfield Hampshire GU32 1HY Lead Inspector Gina Pickering Unannounced Inspection 8th November 2005 10:30 Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westbury House Nursing Home Address West Meon Nr Petersfield Hampshire GU32 1HY (01730) 829511 (01730) 829108 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) Mr Irvine Navid Naqvi Mrs Linda Murray Care Home 70 Category(ies) of Physical disability (70), Physical disability over registration, with number 65 years of age (70), Terminally ill (70), of places Terminally ill over 65 years of age (70) Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user is to be admitted over the age of 70 Date of last inspection 12th July 2005 Brief Description of the Service: Westbury House is a care home situated on the edge of the rural village of West Meon. The home is registered to provide accommodation and nursing care for up to seventy service users, though at the present only up to fifty service users are accommodated at any one time. The home caters for persons that have an acquired brain injury or an illness affecting the nervous system. The home has an occupational therapy facility and a facility for service users to purchase private physiotherapy. The registered manager, Mrs Linda Murray has been in post for ten months. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5.5 hours on the 08/11/2005. The deputy manager is managing the home as the registered manager is on long term leave. Discussion with the deputy manager and those living at the home evidenced that the service users like to be collectively known as residents. This will be reflected throughout the report. The inspector spoke to the deputy manager, five care staff members, the activity organiser, a member of the occupational therapy staff, the cook, and twelve residents. All residents expressed that they like living at the home and are able to make individual decisions about daily activities. One gentleman told the inspector that the home is excellent, the best place he could possibly live. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 A procedure for the assessment of prospective residents is in use and utilised well to ensure that prospective residents needs are met on moving into the home. EVIDENCE: A procedure is in place for the assessment of all residents prior to moving into the home. The manager or her deputy performs the assessment at the prospective residents place of living. A sample of the assessment documents of recently admitted residents was looked at. This evidenced that comprehensive information is recorded of personal, physical, emotional and social needs prior to the decision being made as to whether the home will be able to meet the persons needs. Evidence was available to indicate that assessments are performed of those resident’s at the home who have been in hospital for a length of time to ensure that the staff at the home will be able to meet their needs on return to the home. Discussion with staff members indicated that they believe they have the information to be able to meet resident’s needs on moving into the home. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 & 16 The management of the home ensures that the resident’s rights and decisions are respected and that they are able to retain contact with family and friends and are able to develop friendships within the home. EVIDENCE: Policies and procedures are in place about the resident’s rights to develop friendships within the home and maintain those friendships they had prior to entering the home. Care plans indicate support that the residents need to maintain and develop friendships. Observation and discussion with several residents evidenced that friendships are made between residents, which contributes to them leading a fulfilling life. Residents are able to receive visitors at any time. The deputy manager discussed how staff members support the resident’s choices whether to receive visitors or not. Discussion with staff and the manager suggested that residents are able to exercise their choice about daily activities, personal care and their daily routines. This was supported in conversations that the inspector had with several residents. Care plans indicate that resident’s choice must be upheld. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, & 20 Care planning systems result in detailed information being available of the service user’s health, personal and social needs. Good practices and regular assessments of health care needs of the residents ensure that individual’s personal, health and social cares needs are met. The administration of medications is handled in a safe manner, contributing the health and welfare of the residents. EVIDENCE: Care plans indicate the manner in which individual residents prefer to have their personal needs met. There are an appropriate number of bathrooms that have assisted baths and showers to allow residents choice. Residents are given choice about times to get up and go to bed, this was evidenced in conversations that the inspector had with residents. The health care needs of the residents are monitored in the care planning system. Continence needs, tissue viability, moving and handling, nutrition, and dependency assessments are in place and are reviewed and revised at regular intervals. All residents are registered with one of the local GP’s in the village through which they have access to the multidisciplinary health care team that includes dieticians, physiotherapists, and community psychiatric nurses. One member of staff has received training to allow her to measure residents for Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 11 wheel chairs that speeds up the process of obtaining new wheelchairs for residents. Residents expressed to the inspector that their health care needs are met; if they have any concerns about their health they are able to express it to staff at the home who act promptly and appropriately. Policies and procedures are in place for the administration of medications including a policy about residents administering their own medications that was requested following the previous inspection. Procedures are in place for the disposal of unused medications that adhere to recently implemented regulations. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents are confident that their concerns will be listened to and acted upon. Staff members are aware of issues regarding the protection of vulnerable adults, despite the lack of formal training, thus ensuring that residents are partially protected from the effects of abuse. EVIDENCE: A complaints procedure is in place and displayed for all who enter the home to see. It includes a 28-day time to scale to respond to complaints received. Residents are made aware of the complaints procedure when moving into the home. Discussion with residents evidenced that some of them are aware of the complaints procedure and know whom to express concerns to and suggested that concerns that they raise are acted upon promptly and sensitively. Due to the nature of the illnesses of many of the residents they are unable to retain information, but staff are aware of their usual behaviours and will take into consideration that a change in behaviour of a resident could suggest a dissatisfaction about the service provide and will need to be addressed. A record of all formal complaints received and the action take to resolve the complaint is kept. Formal training for staff members about the protection of vulnerable adults is being addressed. A member of staff has been allocated to attend training that will allow her to give formal training to all staff at the home. The deputy manager had previously been allocated to give this training but due to her having to take over the management of the home this has not been possible. This standard shall be re assessed at the next inspection to ensure staff members have received the required training about adult protection. But in discussion with staff members it was demonstrated that they would take the correct action in the case of a suspected act of abuse. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Resident’s live in an environment that is well maintained and decorated in a fashion that they are content with. Hygiene and cleanliness of the home is generally good contributing to the wellbeing and health of the residents at the home. EVIDENCE: The inspector toured the home viewing all communal areas, several of the resident’s bedrooms, bathrooms, the kitchen, laundry, and the activity room. All areas on the ground, first and second floor are decorated and furnished in a homely fashion. Work has been recently completed fitting all radiators with individual temperature control valves. Radiator guards have been purchased and are in the process of being positioned over all radiators. Bedrooms are furnished and decorated to meet the needs and wishes of the residents, many bedrooms being personalised with resident’s belongings. A rolling programme of redecorating and refurbishing the bedrooms is in place. Bathrooms were viewed to be generally tidy and free from hazards. Residents, which the inspector spoke with, stated that they are happy with the décor and furnishings at the home. One resident discussed with the inspector that she has requested that her bedroom be redecorated; this is in the process of being addressed by the management of the home. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 14 The basement of the home has areas that are shabby in appearances that would benefit from redecoration. Policies and procedures are in place about hygiene and the control of infection. A team of cleaners are responsible for the cleanliness of the home. The home was free form malodours during the course of the inspection. Work has been completed in the kitchen area on the request of the environmental health department to meet food hygiene requirements. The inspector discussed with the deputy manager that one of the bathrooms had various bars of soaps, and resident’s toiletries in it that could pose a risk of cross infection. It was agreed that this would be addressed immediately. The laundry facility was clean and tidy and assessed to pose no hazards to hygiene and infection control. A sluice facility is available on each floor. The home is in the process of increasing the supply of hand cleaning dispensers, including alcoholic gels situated throughout the home to increase the effectiveness of hand washing and reduce the risk of cross infection. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 36 The number and skill mix of staff employed at the home meets the resident’s holistic needs. Robust recruitment procedures are used to ensure the protection of the people living in the home. Residents do not benefit from a fully supervised staff team. EVIDENCE: The inspector viewed a sample of staff training records indicating that staff members receive the training to equip them with skills to meet the resident’s holistic needs. Care staff are being encouraged and supported to undertake NVQ training in care. Residents that the inspector had conversations with suggested that staff at the home have the skills to meet their needs. Care staff in discussion with the inspector demonstrated their understanding of the emotional, social and physical needs of the residents at Westbury House. Formal supervision was discussed with the deputy manager. This requirement from the previous inspection had not been implemented prior to the manager going on leave. It was agreed between the inspector and the deputy manager that group supervision sessions will be used until the return of the manager who it is believed has a process ready to be implemented. This will be reviewed at the next inspection. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 16 Procedures are in place about the recruitment of staff. The inspector looked at four files of recently recruited staff evidencing that these procedures are followed. The files contain two written references, evidence of satisfactory CRB and POVA disclosures and documents indicating overseas staff are permitted to work in the UK. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 Despite the manager being on long term leave the resident’s welfare and safety is protected by the competency of the deputy manager and the staff team. Resident’s opinions and wishes are an integral part of the running of Westbury House. EVIDENCE: At the time of the inspection Westbury House is being managed by the deputy manager as the registered manager is on long- term leave. The deputy has had experience of managing the home in the absence of managers in the past. She is in the process of arranging to study for the registered managers award. The manager had agreed to implement a formal quality auditing process, but due to her absence this has yet to be put in place. However the home continues to seek the views of residents and their representatives in the form of surveys to enhance the quality auditing of the service provided by the home. Resident meetings, staff meetings, care plan reviews and the monthly Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 18 report by a representative of the provider about the service provided by the home continue to contribute to the quality auditing of the home. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbury House Nursing Home Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000011525.V263471.R01.S.doc Version 5.0 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13(6) Requirement The registered person must ensure that all staff receive training about the protection of vulnerable adults. THIS REQUIREMENT WAS PREVIOULSY MADE ON 12/07/05. The registered person must ensure that all care staff receive formal supervision at least six times a year. THIS REQUIREMENT WAS PREVIOUSLY MADE ON 14/01/05 & 12/07/05. Timescale for action 30/01/06 2 YA36 18 28/02/06 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 Refer to Standard YA24 Good Practice Recommendations The basement area should be redecorated to create a pleasant environment for resident’s accessing that area. Westbury House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 House Nursing Home DS0000011525.V263471.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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