CARE HOME ADULTS 18-65
Westbury Lodge 130 Station Road Westbury Wiltshire BA13 4HT Lead Inspector
Tim Goadby Key Inspection 10th & 15th May 2006 08:30 Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 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 Lodge DS0000028438.V295760.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 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 Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Westbury Lodge Address 130 Station Road Westbury Wiltshire BA13 4HT 01373 859999 01373 864512 westburylodge@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes (No. 2) Limited 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) Vacant Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Only the one named service user, referred to in the application dated 9 August 2005, may be in receipt of care due to having been assessed by a person qualified to do so as suffering from a diagnosed clinical mental illness necessitating care and/or treatment. 13th December 2005 Date of last inspection Brief Description of the Service: Westbury Lodge provides care and accommodation for nine adults who have a learning disability. Some service users also experience difficulties associated with sensory loss. The home is owned by Parkcare Homes Ltd, a division of Craegmoor Healthcare, who own a group of homes both locally and across the country. Accommodation in the home is provided over two floors, with seven bedrooms on the first floor, and one bedroom and a semi-independent flat downstairs. All persons accommodated on the first floor must be able to climb stairs without assistance, as a lift is not provided. The flat has a shower room, and the other ground floor bedroom has an ensuite shower. There are two bathrooms for general use upstairs, both of which also have showers. The ground floor also has a sitting room, dining room, kitchen, and laundry. There is a secluded and secure garden at one side of the building. The home is situated on the edge of a residential area, about ten minutes walk from the centre of Westbury. Bus stops and a main line station are a few minutes walk away. A small car park is available at the front of the building, with a driveway on to a busy road. Information for service users is displayed in the home, including some in pictorial formats. Key issues are also discussed with them individually, or within residents’ meetings at the home. CSCI inspection reports are included in these discussions when they are received, and a copy is always available in the home. Fees charged for service users, as at May 2006, range between £665 and £1098 per week. The usual base price for any new admission is £860. Further costs are based on an individual assessment of need. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Key inspection was completed in May 2006. The evidence gathered included pre-inspection information supplied by the service; and a review of regulatory contact since the previous main inspection in December 2005. The latter included an additional inspection visit in March 2006. Two visits then took place to the home. The first of these was unannounced. The second, a few days later, was by appointment. This fieldwork section of the inspection included the following: observation of care practices; sampling of records, with case tracking; discussions with service users, staff and management; sampling a meal; and a tour of the premises. What the service does well: What has improved since the last inspection?
Service users are being supported more effectively by the available staff. Minimum required levels of cover are now being maintained on all shifts.
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 6 There are also more staff in post, and more being recruited, so that there is less pressure on individual staff members to work excessive hours or exhaustive shift patterns. Changes have been made to systems for medication recording, ensuring that these work more effectively for the protection of service users. Any handwritten amendments to printed records are clear. Copies of individual guidance on particular prescriptions are kept in the main medication folder, so that they are readily available for reference when needed. Steps have been taken to update knowledge and skills in the moving and handling of service users, so that those individuals who require this can be more confident that they will be supported safely and effectively. When significant incidents have occurred in the home, affecting the safety and well-being of service users, these have been reported without delay to the CSCI and other relevant agencies. This enhances the protection of service users by ensuring that the home is open, and enables advice and input from other sources. The recording of such incidents has also developed, in response to feedback from other agencies. Records now contain more descriptive detail, and also uphold the necessary principles of confidentiality for the individual service users concerned. Steps have been taken to put more care plans and risk assessments in place, on topics of direct current relevance to individual service users. There have been developments in how service users’ behaviour is described in records. Guidance is now in place to set out what is meant by certain terms. This promotes consistency in record keeping, and provides better evidence of whether a response to a particular incident was appropriate. Following a period when a high number of significant incidents occurred, centred around the behaviour of a particular service user, the situation has become much more stable in recent weeks. Although the service is unable to evidence a direct link with the approaches it has been applying, service users are benefiting from a calmer atmosphere within their home. What they could do better:
The home is presently without a registered manager, so that service users do not benefit from having a suitably knowledgeable and skilled person in place who is directly accountable for their welfare. The manager appointed by Craegmoor in December 2005 has applied for registration, but has not yet demonstrated suitability for this role. Further information in support of the application has been requested from the organisation by the CSCI. Craegmoor also needs to give consideration to how its organisational systems support services when they are going through difficult periods, and when they
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 7 have inexperienced managers. The company has a range of systems and available expertise which should be of benefit at such times. Despite this, they have failed to demonstrate effective oversight and support for Westbury Lodge over recent months. Service users at this home have not received the quality of service which the company has a stated commitment to providing. There are eight continuing or unmet requirements from the previous inspections of December 2005 and March 2006. In addition, a further seven requirements were identified at this Key inspection. Service users’ needs and aspirations are not all being met, placing them at risk of harm. The services offered by the home are not all demonstrably based on current good practice. Nor do they always reflect specialist and clinical guidance. Care plans, risk assessments and management strategies are not clearly in place for all identified issues for the home’s service users. This places some individuals at risk of harm. In particular, there is a failure to define strategies for the management of behaviour; and to properly evidence the use of restrictions on service users’ choice and freedom of movement. Not all service users have equal access to activities and opportunities. There is an awareness of this issue within the home, and of the factors which contribute to it. But, as yet, there are no clear plans about how to make progress, to ensure that all service users benefit from the same quality of life. Guidelines to govern the use of ‘as required’ medication are not fully set out for one service user, who has recently been given such drugs regularly as part of the overall management of behavioural needs. This places the individual at risk that the prescription may be given inconsistently or inappropriately. There is an ongoing need for an overall staffing review in relation to the home. Although the current minimum required levels are now being maintained, it is not clear that these are sufficient to meet all the needs of the service user group. Service users would benefit from confidence that allocated staffing resources can be demonstrated to be sufficient to provide all the services offered by the home. Recruitment of new staff needs to ensure that relevant evidence is obtained in relation to any previous employment that a person has had working with children or vulnerable adults. This will ensure that service users are fully protected, in line with the statutory requirements for registered care services. Service users are placed at risk by deficits in the knowledge and skills of the staff team. The home needs to ensure that all staff receive relevant training, from induction onwards. This must include the undertaking of nationally recognised qualifications in care. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 8 Staff also need to have regular and recorded individual supervision meetings with a senior colleague. This will ensure that service users benefit from staff who are appropriately supported, and who are working to an ethos of continual improvement. Service users need to be confident that quality assurance measures reflect their aims and outcomes. The current service development plan lacks such a focus, as there are no goals based on input from service users. Fire safety measures need attention, to promote the protection of all users of the building. Two separate escape routes from the premises need attention to make them safely accessible to all. In the meantime, risk assessment information needs updating to reflect that there are current difficulties. A number of good practice recommendations were also identified. Choice and independence needs to be promoted across the service user group, with particular attention to the more impaired residents of the home. This will enable all service users to have more access to the kind of opportunities presently enjoyed by the most able. Menus should be reviewed to promote greater variety and choice of meals, and to focus on the nutritional value of the food served in the home. This is also an area where the greater involvement of service users could be promoted. The home’s dining room would benefit from redecoration and refurbishment. This would enhance the appearance of this area, and contribute to a more pleasant environment for service users. Care should be taken in record keeping to ensure that all documents are clearly dated, so that it is apparent how current they are. Service user files would also benefit from the removal of outdated and duplicated material, to reduce the risk of confusion. 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 Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 9 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 Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 10 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): 3 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Standards relating to admissions to the home were not applicable at this inspection. Service users’ needs and aspirations are not all being met, placing them at risk of harm. EVIDENCE: There have been no new admissions to Westbury Lodge since August 2005. The home is presently fully occupied. Although it is likely that one of the current service users will move on in the coming months, no prospective replacements have been referred or assessed as yet. The home cannot demonstrate the capacity to meet all the assessed needs of its current service user group. The range of abilities and impairments of Westbury Lodge’s residents varies widely. This means that they require differing kinds of support. The services offered encompass learning disability and mental health needs, along with some physical health issues for certain individuals. They are not all demonstrably based on current good practice. For instance, person centred
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 11 planning, a key issue for the learning disability field in recent years, has not yet been implemented. Nor do they always reflect specialist and clinical guidance. Input is obtained from various relevant professionals, but it is not clearly transferred into the current support being delivered. The staff team lacks the balance of skills and experience necessary to deliver all the services which the home offers to provide. Levels of knowledge and confidence vary amongst the team, creating inconsistencies in the support available to individual service users. Those who have communication impairments or behavioural needs are less likely to have access to a range of choices and opportunities. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are placed at risk of harm by a failure to have clearly recorded assessments and management strategies for all areas of need and risk. The home fails to show the input of service users to decisions about their own care. Service users can make choices and decisions in their daily lives, but these opportunities need to be promoted more equally for all individuals, regardless of their level of impairment. EVIDENCE: Records for three service users were sampled during this inspection. More care plan and risk management documentation is in place than at the previous inspection visit of March 2006. But this process appears to have been largely reactive. Areas specifically discussed at that previous inspection have been
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 13 addressed, but there is no evidence of progress on other topics. Documents still lack detail and clarity on key need areas. Service user plans do not show the input of the individual concerned, or of other relevant persons. Person centred planning is due to be implemented in the home in the near future, but this initiative has been delayed. At present there is a lack of clear understanding in the home about this important development. Plans and risk assessments have not been kept under review at the times indicated for this to occur. The manager states that this is because of the pressures on staff over recent months, which has limited opportunities to attend to paperwork. There has been input from various professionals on specific topics. Records do not show clearly how this has been linked to individual service user plans. Notes are made when a practitioner has visited the home, and copies are placed on the relevant person’s file of any letters or reports received. But there is no evidence of how such input is being applied in day-to-day care; or whether programmes implemented some time ago are still being pursued. For one service user, active steps are now being taken to seek an alternative placement for them. The service user will need careful support and assistance through this process, which will be their second move in around a year, after many years in their previous home. There is no information in the individual’s care plan about this, and the steps being taken towards it. It was clear from conversations with staff that they are not all aware of what is happening with this person, and the implications for their care over the coming period. Efforts are made to enable service users to have choice in their daily lives. Preferences are respected in areas such as what time people wish to get up. More impaired service users are not yet empowered to make a range of decisions and choices. Guidance on this topic appears in some of the sampled care plans, but not all of them. The new manager is keen to make progress in this area, but has not yet obtained relevant knowledge about possible ways to do so. Risk assessments and management strategies are in place, but are not meeting all necessary criteria. The home’s format includes a space for documents to be signed up to by all relevant people, such as the service user or their representative, and other professionals involved. But this has not been done, so there is no evidence of appropriate sharing of key decisions, on issues such as restrictive interventions. Some known risks are not explicitly addressed. For instance, one service user has been the subject of more incidents of disturbed behaviour from another
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 14 than anyone else in recent months. This suggests a degree of targeting, and highlights a need for specific steps to protect the first service user. But although staff are aware that this is a particular issue, there is no documented protection strategy in place. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 15 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Not all service users have equal access to opportunities and activities. Service users are able to maintain and develop appropriate relationships with family and friends. Service users are placed at risk by a failure to provide appropriate evidence for restrictions on their independence, choice and freedom of movement. Service users would benefit from a review of menus in the home. EVIDENCE: Some service users have limited opportunities to engage in meaningful education, occupation or activities. Staff commented that the new manager is making efforts to increase this.
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 16 Some people attend college courses or other day service facilities for part of the week. One service user is also in the process of accessing employment in Westbury. But overall the current service user group has limited access to such external opportunities. So the majority are reliant on being supported in activities, both at home and in the community, by Westbury Lodge’s own staff. The service has a part-time activities co-ordinator who leads on this, but she is only present on two days each week. Outside the home, there is use of various local amenities, such as shops and pubs. On the first of the visits during this inspection six service users were going out later in the day to attend a circus in Trowbridge. Some service users have proved more difficult to engage in activities outside the home. This may be linked to mental state, anxieties or phobias. Work has been undertaken to try and address these issues, but the lack of recent review of such programmes means it is not clear whether goals are being met. Service users’ participation in the local community varies depending to their abilities and behaviours, and the confidence of the staff team to support these. Access is also limited because the majority of the home’s staff team are not able to drive. In the home, people may undertake various activities in line with their own interests. For instance, one person spends much of the time knitting. Another was seen doing some art work with staff support. A first floor room has been fitted with various sensory equipment. But this was not available for use during this inspection, as it was being used for storage of some recently delivered boxes. A number of service users spend a lot of time in the lounge on the ground floor. In this room, the television tends to be left on most of the time. This includes when music is being played on the stereo as well. It is not always apparent that any service users wish either or both of these to be operating, and the distractions created detract from a calm atmosphere. This issue can be particularly important for people with autistic spectrum disorders. There is information in service users’ care plans about their key relationships, and how these contacts are maintained. Most people have regular arrangements for keeping in touch with relatives, through visits, letters and phone calls. Within the home, although there have been problems amongst the group, there is also evidence of positive and friendly interaction between some service users. There is insufficient evidence to support restrictions which have been implemented with some service users, such as monitoring their movements, or the rationing of drinks. Risk assessments have now been put in place for such areas, but they lack detail about the balance of possible benefits and harms,
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 17 and the reasons for deciding on a particular approach. There is also no evidence to show who has been consulted and involved in the decision making process. Documents contain a space for relevant people to sign up to them, but this has not been done for the examples seen. The process and frequency of review of such restrictions are not set out. The exits from the home are on a keypad lock, for safety reasons. The property is situated near a busy road, with limited visibility in both directions. Menus in the home are drawn up over a six week period. There is no evidence of significant service user input to this process. Observations over recent inspections support comments during this visit that the choice and variety of food tends to be limited. There is little evidence of the use of fresh ingredients. The majority of service users have no specific dietary needs. One person has to have all food liquidised. The dietician has given input, to ensure that the individual’s needs are being met appropriately. Service users can access the kitchen, with supervision. Some are able to make drinks and snacks independently. Staff give support to any service users who need assistance during mealtimes. But staff no longer dine with residents. This can create some difficulties. For instance, it was observed that, when staff sit down to eat the food they have purchased and brought in, some service users may indicate a wish to have the same. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to address their personal and health care needs effectively. A service user who is prescribed ‘as required’ medication would benefit from the home defining more precisely how this is used. EVIDENCE: Service users have varying levels of abilities and needs in relation to personal care. Some are able to be largely independent. Others require differing degrees of support. These issues are set out in care plans. Service users have a variety of physical and mental health needs. These issues are set out in their individual plans. There are systems to monitor and record any key indicators. Other relevant professionals are involved in reviewing and evaluating care. The home has good links with its local GP surgery. A specialist consultant in learning disability also gives regular support to the home, including reviews of service user medication. Mental health professionals are involved closely for those people who need this.
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 19 Sampled records show that service users receive regular health checks in all relevant areas. This includes input from dentists, opticians, and a chiropodist. All current service users have medication prescribed. They all have their medication stored and administered by staff. All care staff undertake this task, once they have received relevant training. This includes instruction from a suitable health professional about the specific administration technique for one drug that people might require. Arrangements for medication storage and recording are appropriate. Drugs are stored securely. The medication folder includes a photo of each service user, and information about the drugs which they take, including the likely effects. Administration records are maintained accurately. Most medication is supplied from the pharmacy in a monitored dosage system. This means that tablets and capsules are portioned out, according to the times that they are due to be taken. Drugs which cannot be supplied in this format, such as liquids, are dispensed in individually labelled containers. Some drugs are prescribed to be given ‘as required’. This means that staff need to make a judgement about when it is appropriate to give the medication. Most service users who have such prescriptions have clear guidance on the criteria for their use. These have been supplied by the consultant prescribing the medication. The forms are kept in the main medication folder, so that they are readily available for reference. The home’s newest service user, admitted in August 2005, does not have the same guidance, as their medication was prescribed by another consultant when they lived in their previous home. Westbury Lodge’s own documentation on this individual contains a brief reference to the use of ‘as required’ medication in the management of behaviour, but does not set out clear guidance on when and how this should be done. The person concerned was administered the particular medication in question several times during April 2006, so it is important to be able to evidence how the judgement to do so is reached. This issue was also the subject of a requirement at the additional inspection visit of March 2006. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. Service users are placed at risk due to a lack of effective planning for management of needs associated with behaviour and mental state. EVIDENCE: Craegmoor has a complaints procedure, which is prominently displayed in the home. Records are kept of any concerns raised, and of the actions taken in response. There are also policies relating to abuse and adult protection. The home is aware of the local multi-agency procedures in this area. Vulnerable adults processes are underway in response to a number of incidents which have occurred in recent months, as appropriate. But the home manager still displays a lack of clear understanding of how these operate, despite direct involvement. She is unable to describe with confidence the process for referring concerns to the procedure, and for initiating an investigation. Strategies for the management of physical aggression by service users do not address all relevant factors. ‘Reactive strategies’ set out possible indicators that a certain behaviour may occur, and what to do if it does. But the response to be implemented is not always set out in clear detail. For instance, staff are instructed to remove a service user from the situation. But it is not
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 21 set out how this is to be done, and whether or not the individual is likely to be co-operative. There is also a lack of detail about strategies to try and prevent any disturbed incidents occurring. The main prevention strategy is a monitoring regime. This allocates responsibility for observation and awareness of all nine service users amongst the staff on duty. There are charts to be filled out at various times during the day to comment on what has been observed. There are some gaps in these records. It was also observed during inspection visits that staff were not always certain who was allocated to which service user, and sometimes had to check with each other what was happening. The home has also recognised the need to have a more proactive programme for reducing and replacing problem behaviours. For the service user most directly concerned in the recent incidents in the home, a full weekly programme is being devised, using pictures and symbols designed to make it accessible to the individual. But, although the programme is said by the home to have been implemented, at this inspection the relevant noticeboards were stored on the floor in the manager’s office, and were clearly not in use. Arising from the vulnerable adults process, there has been lots of input to the particular service user in recent weeks. This has included a number of visits from a specialist behavioural nurse, to carry out observations and give guidance to the home on possible interventions and management strategies. There is no evidence of this advice and input being built into the individual’s care plan. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: The home is clean and hygienic in all areas seen. Maintenance and décor is generally good. The dining room would benefit from redecoration and refurbishment. One member of staff works ten hours each week, split over three shifts, specifically as a cleaner. This enables them to focus on more intensive cleaning tasks. At other times, the rest of the care team are responsible for all cleaning. Service users may also participate, depending upon their abilities and preferences. The home employs its own handyman, who can attend to a variety of jobs as the need arises. External contractors are engaged where appropriate.
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area was poor. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels need further review, to ensure that they address all assessed needs of service users. The home is unable to evidence that all appropriate recruitment processes are in place, to ensure the protection of service users. Staff have not received training in all relevant topics for the support of the current service user group, placing some of those users at risk. More progress is also needed in care staff obtaining nationally recognised qualifications. Staff are not supported and supervised effectively, hindering their ability to deliver a service that meets its users’ needs. EVIDENCE: The home has experienced a period of pressure in maintaining the required staff levels. This has been due to unfilled posts arising from turnover, and the absences for various reasons of some of the current team. Staffing levels are now being maintained at or above the previously agreed minimum. This
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 24 means that there are always at least three staff on duty for all daytime shifts, between the hours of 07.00 and 21.30. At times this increases to four people, particularly when activities are planned to take place. At night there are two waking staff. A separate pool of people are employed to cover nights, although some day staff may work an occasional night shift if necessary. It is not clear that the minimum level of three staff for daytime hours is sufficient for the present situation. The safety of service users and staff has not always been achieved, even with these numbers present. The extensive deployment of staff to attempt to prevent further incidents also impacts on the ability of the service to support other needs. The requirement set at the additional inspection visit of March 2006, for a fuller review of staffing levels, remains relevant. To maintain the current staffing levels, it has been necessary for some people to work intensive shift patterns. This has included many consecutive days or nights on duty, long unbroken periods at work, and tiring mixtures of day and night duties. This situation has eased recently with the appointment of some new staff. Recruitment is ongoing, which should help to alleviate these difficulties still further. Sampled staff records show that the recruitment and selection process meets the majority of the required criteria. Once an appointment decision has been made locally, the checking process is administered centrally, from Craegmoor’s head office. A checklist is in place of the various stages required. One deficit in the recruitment process was identified. Recruitment checks have omitted to obtain references from all relevant periods of previous employment in care work. Two of the three sampled staff records at this inspection had such gaps. For instance, one employee had two written references relating to their most recent employments, which were not in care. But two earlier periods of care work, as declared on the person’s application form, had not been followed up. Where such employment has been for not less than three months, a written reference is required. In any case, there must be written verification of why any previous position in care work finished. Staff have not yet received suitable training to support all the needs of service users. This is partly due to the volume of staff turnover recently, and also because deficits in training begin from induction onwards. Craegmoor has an organisational approach to induction and foundation training which links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with learning disability. Successful completion of this package also provides workers with a pathway into National Vocational Qualifications (NVQs) in care. But the induction has not yet been applied to staff appointed at Westbury Lodge from January 2006 onwards.
Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 25 The home’s percentage of staff with NVQ Level 2 or higher has fallen slightly below 50 , following recent turnover. Progress towards addressing this is delayed by the failure to carry out effective and timely induction of new employees. Training is also being pursued on other key topics relevant to the support of the home’s service user group. This includes the management of challenging behaviour, autism awareness, and manual handling. Some sessions are set to take place in June 2006. Staff have not been receiving regular, recorded supervision meetings since the new manager came into post in December 2005. Craegmoor has devised a new approach for implementation. This includes a ‘Personal Performance Agreement’ booklet for each individual staff member, in which records of their own sessions and agreed targets will be kept. This is now due to begin, with the intention that sessions will be held every six weeks. Staff meetings have restarted, and the intention is for these to be held once a month. Notes are kept of the meetings, so that any staff unable to be present can read what was discussed afterwards. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 26 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): 39, 41 & 42 Quality in this outcome area was poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home is currently without a registered manager with appropriate knowledge, skills and experience, placing service users at risk that the home may not be run effectively. Quality assurance measures need to demonstrate that the home is conducted and developed in line with service users’ needs and preferences. Effective record keeping is maintained, upholding service users’ best interests. Some further improvements would be beneficial. Fire safety measures need attention, to ensure that the welfare of service users is promoted and protected. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 27 EVIDENCE: The home’s previous registered manager left Westbury Lodge in late 2005. The former deputy manager, Mrs Gill Hodson, was appointed as home manager in December 2005, and applied to the CSCI for registration as manager in January 2006. At the time of this Key inspection, she has failed to demonstrate that she has the appropriate knowledge, skills and experience to fulfil this role effectively. In the absence of a suitable registered manager, there has been a lack of leadership and structure within the home. Craegmoor, as registered provider, has been asked to provide additional information to demonstrate how they will ensure this situation is resolved. Mrs Hodson has had limited time to attend to managerial and administrative tasks over the months since her appointment, due to the staffing pressures on the home. This has meant she has had to spend a lot of time working on shift as part of the care team. More support from the organisation could be of assistance in addressing this difficulty. Craegmoor’s services are extensively audited by the organisation. It has a ‘Clinical Governance’ team, aiming to ensure that all establishments achieve a minimum standard of performance, and then promote them to move beyond this to reach a level of excellence. The manager has to submit various weekly and monthly reports. There are also visits to the home by senior managers. Despite this input, the company has failed to demonstrate effective oversight and support for Westbury Lodge over recent months. Communication channels between the home manager and the various other Craegmoor personnel who could be of assistance to her have not always operated as intended. The manager has not yet become familiar with all the support systems in place. Service users’ meetings are held once a month. Records are kept of these sessions, which are an opportunity for the home’s residents to make their views and wishes known. But there is no clear link from such consultation to the overall quality assurance system for the service. The home has a business plan, dated January 2006, which includes various targets. These include service viability, staff issues, and operational issues. But none of the present objectives are based on service users’ views; nor do they reflect their aims and outcomes. Relatives have also been surveyed for their feedback in the past, although this exercise has not been carried out recently. Records are maintained on a range of topics as required. Ongoing records of care for service users are detailed and informative, with entries being made three times per day by staff on different shifts. Evidence is kept of various Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 28 areas, such as contact with health professionals, activities undertaken, and contact with families. Some improvements could be made. Not all documents are dated, which makes it hard to judge whether or not they remain relevant. There is also some duplication of information. Older versions of records could be removed and archived, so that current files are more user friendly, and any scope for confusion is reduced. Evidence is available to show that a range of health and safety checks are carried out. This includes both internal monitoring, and programmed visits from relevant contractors. Full audits of the premises are carried out every six months. The most recent took place in April 2006. The fire log book shows that all required checks and instructions relating to fire safety are carried out at the prescribed intervals. The fire risk assessment for the premises, conducted by an external contractor, was last updated in September 2005. This identified a number of issues for action, most of which have been resolved. But the need to create a ramp at the exit from the lounge to the garden, so that this escape route is readily accessible to all service users if required, has not been addressed. More recently, the home’s external fire escape stairs from the first floor have been declared unsafe. They have therefore been taken out of use, except in an emergency situation. The stairs are due to be replaced. In both cases of the ramp and the stairs, risk assessment information has not been clearly updated to reflect the current issues arising from these defects. There is no indication of how the situations are being kept under review, or what is being done to ensure that the necessary works are carried out as soon as possible. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 29 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 Standard No Score 1 X 2 N/A 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X N/A X 2 X 3 2 X Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 30 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 YA3 Regulation 12-1 14 Requirement The persons registered must demonstrate the home’s capacity to meet all assessed needs of individual service users, via an initial review of care plans, leading to an action plan with suitable timescales. Timescale for action 31/08/06 2 YA6 12-1,2,3 15 31/08/06 All service users must have individual plans for all assessed needs, drawn up with their involvement and that of relevant other persons. The plan must be reviewed and updated to reflect changing needs, and in any case at least every six months. COMMENT: Requirement carried forward from previous inspection, with an extended timescale for compliance. 3 YA9 12-1 13-6 15 The persons registered must ensure that there are documented risk assessments and management strategies in place for all key needs of all service users. COMMENT: The home has made 31/08/06 Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 31 progress on this requirement. Further work is needed to ensure that risk assessments contain all relevant detail, and are kept under review. 3 YA9 17-1a Sch31b,3q 12-1 16-2m,n This part of Regulations also applies to the above Requirement. The persons registered must ensure that all service users receive suitable support to access appropriate opportunities for employment, education or activities. Any restrictions to service users’ independence, choice and freedom of movement must be agreed in their individual plans. COMMENT: Requirement carried forward from previous inspection, with an extended timescale for compliance. 5 YA16 17-1a Sch3-3q 12-1 13-2 This part of Regulations also applies to the above Requirement. Guidelines must be available for the use of all ‘as required’ medications, to ensure that they are used within the prescriber’s instructions. COMMENT: Requirement carried forward from previous inspection. 6 YA20 17-1a Sch3-3m 15 17-1a Sch3-1b This part of Regulations also applies to the above Requirement. Where needed within individual plans, there must be clear and objective guidance for the
DS0000028438.V295760.R01.S.doc 31/08/06 4 YA12 31/08/06 5 YA16 12-1,2,3 15 31/08/06 31/08/06 6 YA20 31/05/06 31/05/06 7 YA23 31/08/06 Westbury Lodge Version 5.2 Page 32 management of behavioural needs, with strategies to uphold the protection of service users and staff. COMMENT: Requirement carried forward from previous inspection, with an extended timescale for compliance. 8 YA32 18-1a,c The persons registered must provide an action plan for steps to achieve the minimum target of 50 of care staff obtaining NVQ Level 2. The persons registered must undertake a review of staffing levels, to ensure that these are in line with the needs of service users. A suitable plan must then be put in place for any actions identified. COMMENT: Requirement carried forward from previous inspection. Timescale for compliance has not yet expired. 10 YA34 7 9 19 Sch2-3,4 18-1a,c Recruitment checks for all staff must include the statutorily required information relating to any person’s previous work with children or vulnerable adults. The persons registered must ensure that staff receive suitable training to enable them to provide effective support to service users. COMMENT: Requirement carried forward from previous inspection. Timescale for compliance has not yet expired. 12 YA36 12-5 18-2a Staff must receive appropriate support and supervision, via
DS0000028438.V295760.R01.S.doc 31/08/06 9 YA33 18-1a 30/09/06 15/05/06 11 YA35 30/09/06 31/05/06 Westbury Lodge Version 5.2 Page 33 established arrangements for briefings, and regular recorded individual supervision meetings. COMMENT: Requirement carried forward from previous inspection. Timescale for compliance has not yet expired. A new system is now set to be implemented. 13 YA39 12-2,3 24 The development plan for the home must reflect aims and outcomes for service users; and include timescales linked to an audit at least annually. (Timescale of 31/03/06 not met) The fire risk assessment must be updated to reflect issues affecting safe exit routes from the building. Suitable steps must be taken to ensure that all designated fire exit routes are safe and accessible for all users of the premises. 31/08/06 14 YA42 17-2 Sch4 -14 31/05/06 15 YA42 23-4b 30/06/06 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 3 Refer to Standard YA7 YA17 YA24 Good Practice Recommendations Steps should be taken to promote opportunities for choice and decision making for all service users. There should be a review of menus, in consultation with service users and others, to ensure the provision of varied, nutritious and enjoyable meals. Consideration should be given to the redecoration and refurbishment of the dining room, to enhance the quality of this area, and improve the atmosphere at mealtimes.
DS0000028438.V295760.R01.S.doc Version 5.2 Page 34 Westbury Lodge 4 5 YA41 YA41 Care should be taken to ensure that all records are clearly dated, so that it is clear how current they are. Consideration should be given to the ordering of service user files, to remove outdated material and reduce duplication. Westbury Lodge DS0000028438.V295760.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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