Inspection on 05/11/07 for Westcliff House

This inspection was carried out on 5th November 2007.

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

Westcliff House 21/09/06

Westcliff House 09/02/06

Westcliff House 02/09/05

Westcliff House 24/11/04

Westcliff House 26/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Westcliff House 24/26 Westcliff Dawlish Devon EX7 9DN Lead Inspector Peter Wood Unannounced Inspection 05 & 06 November 2007 10:00 Westcliff House DS0000003801.V349323.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 Westcliff House DS0000003801.V349323.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. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westcliff House Address 24/26 Westcliff Dawlish Devon EX7 9DN 01626 862260 01626 867349 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) Mrs Christine Ann Dodge Christopher Hardwidge Care Home 29 Category(ies) of Learning disability (29), Learning disability over registration, with number 65 years of age (10) of places Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered only for the 10 named people who live in the homes with a learning disability over the age of 65 21st September 2006 Date of last inspection Brief Description of the Service: Westcliff House cares for up to 29 people with learning disabilities, 10 of whom are named people who are aged over 65 years. The home is situated on the main road into Dawlish town centre, with garden and patio areas to the front. The home is only a short walk to the local shops and town centre amenities, and on bus and train routes. The premises are made up of two terraced houses that were initially two separate residential homes but are now registered as one. The Roborough wing has six single bedrooms within an annexe to the main building having a separate entrance but also linked to the main house. Each bed-sitting room is large and has kitchen as well as sleeping and sitting facilities. In this part of the premises there is a shower/toilet for every 2 people who live in the home. In the main part of the premises there are a further 5 fully self-contained flats each having a living room with microwave cooking facilities, a bedroom, and a bathroom. Two of these flats have two bedrooms and are shared at present. There is also a communal lounge, dining room and kitchen. The homes office is situated in the Roborough wing. The Sidborough wing is a more traditional style care setting with single, and one double bedrooms of which five are en-suite, communal toilets and bath/shower facilities, lounges, dining rooms and kitchen. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken over one and a half days in November 2007. Our focus during this inspection was to inspect all key standards and to seek the views of people who live at the home, staff, relatives and professional visitors to the home, including using survey forms. Eight people who live at the home returned a survey form “Have your say about Westcliff House”. Seven staff returned the survey form for staff. One health professional returned a survey form and one survey form was returned by a relative, carer or advocate. We met the owner and spent considerable time with the registered manager examining documentation, particularly that relating to client assessment and care planning, staffing and health and safety. We examined the care files of four people who live in the home. This was to provide evidence that the home has a proper assessment and care plan, and provides appropriate care in a safe environment for people who live there. We also examined the personnel files of four staff who work in the home. This was to provide evidence that the home has proper recruitment, training, induction and supervision arrangements. We then cross-checked this evidence with what people who live at the home told us during the inspection visit and in the survey forms, and what other people told us. This cross-checking process is called “casetracking”. We consulted staff on duty. We consulted all those who live at the home who were at home at the time of the visits, and joined them for lunch. We undertook a full tour of the public parts of the building, and also saw most bedrooms of people who live at the home. The inspection process also includes a review of the Annual Quality Assurance Assessment (AQAA) questionnaire completed by the owner and manager, which is quoted throughout this report. The current fee levels are individually negotiated from £475 dependent on level of care required. Copies of inspection reports are available from the home or the Commission’s website. What the service does well: The owner and manager write in the Annual Quality Assurance Assessment (AQAA) that: “We pride ourselves on being a fairly unique residential home, that is run well and has the look and feel of any private accommodation within the community through its personalised flats and bedrooms, communial rooms, equipment and decor, We listen and act on appropriate suggestions from both residents and staff, Everyone who lives and works at Westcliff is treated with respect and dignity, The food is of a high standard.” Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 6 The needs of people who live in the home are assessed before admission. These generate proper care plans to enable staff to offer appropriate care and support and to enable people who live in the home to be as independent as possible. People who live in the home lead interesting lives, maintain contact with family and friends, and are part of the wider community. They receive support with personal and health care in ways they prefer and require. The home’s policies and practices protect residents from abuse. People who live in the home enjoy a clean and safe home which is well run and are properly supported by good staff. What has improved since the last inspection? What they could do better: The owner and manager write in the Annual Quality Assurance Assessment (AQAA) that: “All things listed in Previous standards, we will do this by keeping Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 7 high standards in all disciplines, reviewing our procedures by communicating well with residents, staff and other proffesional bodies.” It was not necessary to make any requirements at the site visit, instead several best practice recommendations were made. While the survey returns from people who live at the home were overwhelmingly positive, many indicated that they did not receive enough information about the home before they moved in so they could decide if it was the right place for them. It is recommended that the manager gives sufficient information to help prospective clients make that decision. Daily records should reflect that the resident’s care plan is being followed. Where necessary behavioural management plans should be in place. 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. The summary of this inspection report can be made available in other formats on request. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 8 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 Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people who live in the home are assessed before admission. This ensures that the home can properly meet their needs. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: “We have a very thorough assessment process where the needs and wishes of the prospective resident are central to the whole process. We travel to the prospective resident or invite residents and family to the home to make initial contact.” We examined the care files of four people who live in the home. This was to provide evidence that the home has a proper assessment process which ensures that the home can properly care for people who come to live there. We then cross-checked this evidence with what people who live at the home told us during the inspection visit and in the survey forms, and what other people told us. This cross-checking process is called “case-tracking”. Each person who lives at the home had an assessment carried out by the registered manager before admission to Westcliff House. Previous assessments were not always Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 10 particularly comprehensive and there was not always a placing authority assessment. However, since the last inspection the manager has completed more in-depth personal care and health action plans for all people who live in the home, using Standex stationary. The registered manager believes that this new process and format will greatly improve the current care planning system at Westcliff based on the person-centred principles of maximising the person’s independence and skills. Although all people who live in the home agreed they were asked if they wanted to move to this home, many indicated in their survey returns that they did not receive enough information about the home before they moved in so they could decide if it was the right place for them. The owner and manager are recommended to take these comments on board when admitting new clients. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Proper assessments generate appropriate care plans for people who live in the home. This enables staff to understand their needs and goals and the action staff need to take to enable people who live in the home to be as independent as possible. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: “The development of individulised care plans which are extremely person centred. Risk assessments are carried out and residents are free to make their own decisions on lifestyle and care. Residents take an active part in prospective staff recruitment. Where appropriate residents attend self advocacy meetings and training.” All people who live in the home have quite good assessments, including risk Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 12 assessments, which appropriately generate care plans. The home also maintains a system of “daily recording”. While some of these care plans included some goals, they tended to be quite general, without specifying what action needs to be taken to achieve those goals, and without much linkage with the “daily recording” which could be used to evidence the implementation of the care plan. It is recommended that the manager considers the new documentation as a true system to evidence: that the needs, abilities, disabilities, aspirations etc of people who come to live at the home are thoroughly assessed; that a comprehensive care plan is generated from that assessment, and that the implementation of that plan is recorded in the “daily recording.” When we spoke to the registered manager it was evident that he had an indepth knowledge about the needs of people who live in the home and what action was taken to meet their needs. However this was not always recorded in plans, and there was not always clear guidance for staff on what action to take with regard to needs and risks. When we spoke to people who live in the home some said they had been involved in their care planning process and knew what was written about them. Some people who live in the home are able to read plain text, while others told us that they understand better the more user-friendly format using pictures. The home is now using various user-friendly formats so that all their clients can better understand notices, care plans and other documentation which was previously just in ordinary words. It was not always easy when reading the care files of people who live in the home to evidence that the home attempts to maximise their independence. However, the home promotes the independence of people who live in the home in a number of ways: “[The home] holds regular Residents meetings and document Minutes; Encourages residents to take an active part in the way the home is run ie sit in on staff selection interviews, plan menus. Sends out and actions Service User satisfaction questionaires. Keeps in contact with Next of kin, families and friends. Review our policies.” Records showed that issues raised in meetings and in the questionnaires were dealt with by the manager with feedback given to the people who live in the homes. People who live in the homes are encouraged and supported to be as independent as possible in managing their own finances. Money handled by the registered manager is suitably accounted for and people who live in the home who were consulted said they were happy with the way their money was handled. Some people who live in the homes attended self - advocacy groups in the community. Survey returns from people who live in the home indicated that they felt able to make decisions about what to do during their day. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home lead active interesting lives, are encouraged to maintain contact with family and friends, and be part of the wider community. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: [We] “Provide a well established system to promote independence. Have good links and a proven track record in liaising with authorities in finding both work and voluntary placements. Help residents become part of the community (taking part in Carnival Processions etc.) Provide regular trips and outings of choice. Stringent induction routines that ensures policies are adhered to regarding, privacy etc. Menus are constantly being reviewed and changed where requested.” Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 14 We consulted all people who live in the home who were at home at the time of the inspection visit. Evidence from these discussions, and those with the staff and manager, coupled with written evidence such as from care plans, home meetings and survey returns, indicated that people who live in the home were involved in lots of activities, educational development, and work experience. Some people who live in the home were able to access the community unsupported and said they shopped for themselves, buying food for their breakfast and lunch with money provided by the registered provider. People who live in the home told us about their recent holidays and involvement in community festivities like the town carnival. They made good use of evening classes and clubs locally run for people with learning disabilities. The home encourages people who live in the home to retain or take up hobbies. We saw an example of needlework and saw another person who lives in the home working on a jigsaw in her bedroom, while another was busy washing a car. Some people who live in the home are encouraged to cook their own breakfast and snack lunches and help with cleaning their bedrooms. Family contact is encouraged and supported at Westcliff. A relative commented: ”All residents seem well and happy. I visit frequently and feel that this reflects on the running of the home.” A professional visitor agreed with that comment, repeating: “Everyone at Westcliff House seems very happy. They seem to be more like a family.” Relationships are encouraged and supported as well, with partners able to share facilities, and advice and guidance given appropriately and sensitively about relationships. All people who live in the home have locks on their bedroom doors and keys provided. The flatlets have doorbells too. We shared a lunchtime meal of a hot dog and roll with some of the people who live in the home. Others had cheese on toast, pizza or a salad and said they had a choice. A four-week menu is in operation and people who live in the home were asked for their views on the menu during meetings. Their weight was regularly monitored, and, although risk factors like obesity were recorded in care plans, it appears they are not always being acted on. A relative commented: “I have some concerns about my relative’s weight. Perhaps some form of exercise for all residents could be arranged, if possible.” We saw that some people who live in the home had drink-making facilities in their bedrooms, following a risk assessment to ensure they would be safe with such equipment. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home receive support with personal and health care in ways they prefer and require. The home’s policies and practices regarding medication administration protect residents. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that:[We] “Provide choice of timings and staff who give personal support within reason. Provide excellent all round health care support by visiting professionals.” We examined the files of four people who live in the home as part of case tracking. We saw several examples of how input from doctors, psychiatrists, community nurses and other professionals was appropriately sought. We saw that care plans indicated how personal support was given to those people who live in the home who needed it. People who live in the home confirmed that staff support was given in ways they prefer. “The staff are very helpful.” Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 16 We observed the procedures for storing, administering and recording medication. Medication is stored securely in a purpose built cabinet, with controlled drugs also stored appropriately. A Lloyds Pharmacy Monitored Dosage System is in place, which helps to reduce any errors. A representative from the pharmacy visits to check the system is operated properly. A bound controlled drugs book is now used to record the one medication under the controlled drugs legislation. All staff administering drugs had received appropriate training. Two people who live in the home currently self-administer their own medication, which is stored in locked receptacles. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are protected from all forms of abuse and know that any concerns they may have are listened to and acted on. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: [We] “Listen to our residents’ concerns and views as they arise and act upon them where appropriate. Use the key worker system to ensure residents feel at ease about making complaints. Provide different forums where issues can be raised. Use quality questionnaires with the residents.” We consulted all people who live in the home who were at home at the time of the inspection visits, and received eight survey forms. All response from those who live in the home indicated that they were clear about whom to go to if they had a concern. They said they would either go to the registered provider, the registered manager or staff. They also said that they were listened to, and action was taken if they were not happy. The complaints book recorded that concerns raised with the registered manager were dealt with in a timely fashion. Two concerns were brought to our attention during the inspection visits, though these were about care management rather than the home. The Commission has not received any complaints about Westcliff House since the last Inspection. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 18 The registered manager is a Protection of Vulnerable Adult trainer. Coincidentally, he was undertaking staff training at the other home owned by the same proprietor when we were inspecting that home. The training was excellent, giving us confidence that staff at this home would be appropriately trained. We saw that records indicated that all staff had received training. Staff consulted or who returned survey forms demonstrated they understood the adult protection procedures. The registered manager was able to demonstrate that adult protection issues are dealt with appropriately. Throughout the year the registered manager and registered provider have reported significant incidents to the Commission. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home enjoy a homely, clean and safe environment. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: [We] “Provide a very homely and safe environment. All flats and rooms suit the individual needs of each resident. Promote independence through equipment in flats.” We undertook a partial tour of the premises, including all the communal rooms, kitchens and laundry and those bedrooms that we were invited into. Westcliff House consists of two large old buildings, previously registered as separate care homes. These old buildings require regular maintenance and renewal to keep the home up to scratch. The registered provider does this through an on-going maintenance programme, probably undertaken by Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 20 members of her own family, including regular environmental checks and a yearly renewal programme where carpets and wall decorations are regularly replaced. A cleaner and care staff carry out the cleaning, with people who live in the homes encouraged to be involved too. All of the bedrooms and flatlets that we saw were clean, tastefully decorated and full of personal possessions that reflected the personality, hobbies and interests of the inhabitant. People who live in the home told us they were happy with their bedrooms and flatlets. The laundry was tidy and clean. Toxic cleaning products are now kept securely locked away in a cupboard in the laundry, following a recommendation at the previous inspection. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are cared for and supported by staff in sufficient numbers and with the qualities, skills, and qualifications to meet their needs. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: “Training: 80 of staff hold NVQs; 20 awaiting confirmation. Have a very effective staff team. Involve residents and take their views seriously in the process of staff recruitment and selection.” Four care staff are on duty during each day, and the team is split so that one staff member works in the part of the house where the more independent people who live in the homes live, and three work in the other side. The registered manager is also in the house every weekday We examined the personnel files of four staff to ensure that proper recruitment, induction, training and supervision arrangement were in place. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 22 We also received the Annual Quality Assurance Assessment (AQAA) from the registered manager. Discussions with the registered manager and staff complemented this documentary evidence. Staff reported that the correct recruitment procedures were carried out with them, including an application form, health form, POVA First (a check against a list of people considered unsuitable to work in care settings) and CRB (Criminal Record Bureau) checks and ID (identity) checks being carried out before employment. In the files examined a written interview format was now being used following a recommendation at a previous inspection to ensure that decision-making with regard to issues around staff fitness were now being recorded. Staff told us that the training they received was good and helped them with the people who live in the homes they cared for. A training development plan for the staff team showed that training included health & safety, an induction and foundation course, first aid, risk assessment, moving and handling, medication administration, food hygiene, infection control, POVA, fire awareness and epilepsy training. Staff attended specialist learning disabilities training when it was available. Some staff were undertaking NVQ training, reaching 80 , far exceeding the 50 target. All staff who returned their surveys commented on the training they received: “Done NVQ2”. “Give you plenty of training.” “Regular Training.” “Staff are kept up to date with all the training they need to know.” “It makes sure everyone is comfortable and cared for in the way in which they are all entitled to.” “Plenty of training given. Enough staff to provide excellent care for the clients and quality time with them.” “Good quality care for residents in out care. Perfect support for staff. It is always clean and tidy.” We observed that staff were courteous and respectful when interacting with people who live in the home. They told me that the staff, including the registered manager, were kind and helpful. Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live here benefit from a home, which is well run, in their best interests, by a competent owner and manager. EVIDENCE: The registered manager writes in the Annual Quality Assurance Assessment (AQAA) that: [We] “Communicate well with staff and residents. Set high and achieve good personal standards. Make staff feel valued. Have a very open and transparent management system.” The owner of Westcliff has owned this home, and owned and managed another care home nearby, (also for adults with learning disabilities, and with mental Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 24 health needs), for many years. She has proved through contact with the Commission over those years, and during the visits that she is both experienced, knowledgeable and enthusiastic about working with people with mental health needs and learning disabilities. She also has NVQ 4 and demonstrated a clear determination to continue to improve the service with innovative ideas for the future. The registered manager has also shown integrity, honesty and a genuine enthusiasm for the people who live at Westcliff House. He and the registered provider demonstrated a clear determination to continue to improve the service with innovative ideas for the future. The registered provider and registered manager have implemented a comprehensive Quality Assurance system, which include the views of people who live in the home and their relatives. It was previously recommended that the registered provider formalise her contact with the Home into a monthly audit as required in the Care Homes Regulations. The Annual Quality Assurance Assessment (AQAA) and records examined during the inspection visits showed that staff undertook a range of health and safety training including first aid, food hygiene, fire awareness, manual handling and infection control. The fire records examined were up to date. The AQAA also indicated that required checks on gas, heating, water, wiring and adaptations were being carried out appropriately. The registered provider employs an external company to audit the health & safety aspects of the service, and action was taken on any shortfalls. Comments within survey returns from everyone were complimentary. A relative commented: ”All residents seem well and happy. I visit frequently and feel that this reflects on the running of the home.” A professional visitor agreed with that comment, repeating: “Everyone at Westcliff House seems very happy. They seem to be more like a family.” Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 X 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 3 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 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations It is recommended that the manager gives sufficient information about the home to prospective clients before they move in so they can decide if it is the right place for them. Daily records should reflect that the resident’s care plan is being followed. Where necessary behavioural management plans should be in place. 2. YA6 Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Westcliff House DS0000003801.V349323.R01.S.doc Version 5.2 Page 28 - 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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