Inspection on 09/02/06 for Westcliff House

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westcliff House 05/11/07

Westcliff House 21/09/06

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 Annie Foot Unannounced Inspection 10th February 2006 10:00 Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 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.V270443.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V270443.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westcliff House Address 24/26 Westcliff Dawlish Devon EX7 9DN 01626 862260 NONE 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.V270443.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered only for the 10 named residents with a learning disability over the age of 65 The home is registered only for the 1 named out of category resident Date of last inspection 2nd September 2005 Brief Description of the Service: Westcliff House cares for up to 29 residents with learning disabilities, 10 of who can be aged over 65 years old. The home is situated on the main road into Dawlish town centre, with patio areas to the front, and a small garden across the main road. There is only a short walk to the local shops, amenities, and bus and train routes. The premises are made up of two terraced houses that were initially two separated residential homes but now function 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 bedroom 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 residents. In the main part of the premises there are a further 5 fully self-contained flats each having a living room with 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.V270443.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was unannounced and the second of the year took place during the morning of 10 February 2006. The manager Christopher Hardwidge was on duty and present through the inspection. Discussions also took place with the owner; Christine Dodge was working at the home. The purpose of the inspection was to follow up on the progress of requirements and recommendations made at the previous inspection and to cover other outstanding standards. All of the requirements and recommendations had been addressed and all apart from an element of one had been fully met. Three other members of staff were on duty; they were met and participated with the inspection. 10 service users were met and several were spoken with during the inspection. The home is currently providing accommodation and care for a very wide age range of service users, from 19 years – 81 years of age. A partial tour of the premises took place. Care plans; medication, complaint and other care records were examined. A pre inspection questionnaire had been completed by the home in advance of the inspection. One comment card was received. All of the service users appeared at ease in their surroundings and several were pleased to show their rooms to the inspector. Two service users said, “this is the best home we’ve lived in “, others said the manager was “good at helping with their money”. What the service does well: What has improved since the last inspection? What they could do better: Work has already begun on developing a comprehensive quality assurance manual. This work needs to be completed and systems developed for Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 6 monitoring and reviewing the service provided. Surveys, which include the views of service users, families and other stakeholders, should be developed with reports made available to interested parties. The purchase of a Controlled drugs register would assist in the homes ability to ensure that drugs are appropriately checked 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. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 7 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.V270443.R01.S.doc Version 5.1 Page 8 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): 1, 4 The home provides prospective service users with written details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The newest service user at the home was able to confirm that they had visited the home at least twice prior to admission earlier in the week. A minor adjustment is needed in the statement of purpose in detailing the owners experience and qualifications. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 9 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): 7,9 Care planning systems enable staff to provide personalised care and support to meet resident’s needs. Systems in place ensure that service users are involved in decisions that affect their lives. Residents are encouraged to develop independent living skills. EVIDENCE: Pre assessments are undertaken to ensure that the home has the ability to meet a prospective service users needs. Both the owner and manager are clear that no one will be admitted to the home unless they consider they are able to meet the needs. The manager and key worker develop a care plan involving the service user during the first few weeks. From discussions with the manager it is clear that constructive working relationship exists between the home and local statutory Learning Disability teams, who are able to provide support and advice as required. Regular service user meetings are held at the home, hosted by the manager. Notes are made and actions recorded. Four service user files were examined. Risk assessments are in place and in some cases these are comprehensive. Risk is assessed on an ongoing basis Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 10 and is recorded. Care plans are reviewed on average every six months with the involvement of the service user. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 11 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): 13, 15, 17 Service users benefit from living close to community facilities and amenities in order to live an independent life style. Service users are guided and supported in their personal relationships. Meals in the home offer choice and cater for special dietary needs. EVIDENCE: Service users living in Roborough were observed to come and go as they choose. One service user currently works at a local supermarket, under a therapeutic placement. The manager and owner are keen to develop similar outlets for other service users to obtain work related opportunities. Staff encourage service users to participate in local activities. Family and friends are welcome at the home. Where potentially intimate relationships develop support and guidance is offered to assist in service users making appropriate decisions. There is a five-week menu in place. In Sidborough service users eat all meals together, unless they have chosen to eat in their room. Alternatives are offered on an individual basis and not listed on menus. Drinks are available throughout the day. Lunch on the day of inspection was homemade soup with Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 12 pasta and bread, followed by fresh fruit. The senior carer on duty had made lunch on this occasion. Service users said they enjoyed their food. In Roborough service users are encouraged to make their own breakfast and lunch and eat together in the evening. The owner prepares meals in Roborough. The manager is looking at other options of providing a more nutritious and balanced diet based on less carbohydrate. Primarily, this is to address the potential weight problems of some service users. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 13 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): 20, Systems for the administration of medication are clear, with arrangements in place to ensure service users medication needs are met. EVIDENCE: Administration of medication was observed and seen to be complete. Medication is stored securely in a purpose built steel cabinet. Controlled drugs are secured within a further locked cupboard within the cabinet. The Lloyds MDS system is in place with regular visits from the pharmacist. Staff are trained before administering medication. Controlled drugs are in use for one service user. Currently these are listed on the MARS sheet, signed and witnessed by two members of staff. There is no CD register in use and no apparent system for checking stock. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 14 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 The procedures for service users to raise complaints and concerns are robust. Service users benefit from knowing that concerns raised will be dealt with in a prompt and timely manner. EVIDENCE: The manager takes a proactive approach to complainants encouraging service users to raise any issues or concern or worry. This has resulted in lots of little complaints, which have been quick to resolve. Often verbal complaints raised at service user meetings will be dealt with immediately. The manager attended the multi-agency training in the protection of vulnerable adults and is a POVA trainer. All service users have a copy of the complaints procedure, which is also displayed, in the home. There has been 1 complaint since the last inspection. The complaints record book was inspected and details of the investigation read. The investigation was thorough and appropriate action and outcome followed through. Investigation records are stored confidentially. The procedure to following event of abuse has been reviewed and is now fully complete. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 15 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): 24,25,28,30 The standard of the environment is good, providing service users with a safe, clean and comfortable home. EVIDENCE: A partial tour of the premises was made. Several service user rooms and flats were seen and all communal shared spaces were seen. The buildings are old and the maintenance needed to keep the home in good order is ongoing. All the communal areas are freshly decorated. The lounges are spacious. Shared spaces are well maintained but it was noted that were no pictures on the walls. The manager said that these were waiting to be replaced following redecoration. The owner and manager have a good understanding of the areas of the home, which need to be improved. Service users rooms, flats and bedsits all vary in size and layout. Some are in better condition than others, but all service users spoken to were very happy with their rooms. The manager said that rooms are usually redecorated before a new service user moves into a room. From interactions between the manager and service user it was apparent that service users had no hesitation it mentioning where something was lacking. The curtain had come down in one Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 16 service user’s room. The manager was observed reminding them to raise any such issue with him so that a prompt repair could be done. One domestic staff member is employed. All areas of the home were clear and hygienic with no hint of odour. The kitchen in Sidborough is in need of refurbishment. The manager said this was planned. The owner is committed to providing a standard of accommodation and prioritises resources to ensure that improvements are made. The Environmental Health Department visited in January. The report was seen with no recommendations. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 17 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): 35 Service users benefit from experienced staff, with the ability to meet individual needs. EVIDENCE: Three care staff were on duty and spoken with. All said they enjoyed working with the service users. Interactions observed between staff and service users were appropriate. There is a comprehensive staff training programme in place. The annual training programme, built on LDAF principals was seen. There is wellorganised system in place to record attendance at training sessions. 5 staff are achieved NVQ level 2 and a further 4 are waiting for a place. The owner and manager have a strong commitment to provide appropriate and relevant training for the staff team. The manager has a strong interest in this area and is responsible for the programme. Equal opportunities and disability equality training has not yet been offered and this is recommended. Staff meetings are held approximately every 6 weeks. Staff are expected to attend. There are currently staff vacancies and the home is recruiting to fill gaps in the rota. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 18 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): 38, 39 The conduct and management of the home ensures that service users and staff benefit from a clear sense of direction and leadership in the interests of improving and enhancing individuals’ lives Service users benefit from the continuity of a stable management team. EVIDENCE: The owner provides a clear sense of direction and vision for the home. The manager is well supported by the owner, in providing leadership for staff and stability for service users. Work on the quality assurance system is progressing but more work is needed to complete the process. The quality manual is almost complete and the manager is systematically working through each item and prioritising action as required. The last service user survey was undertaken in May 2005. Processes for surveys were discussed and it is recommended that surveys be repeated at least twice a year involving the views of service users, families, friends and other stakeholders. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 x 3 x 4 3 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 3 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x 3 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x x 3 2 x x x x Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement Work on the quality assurance system needs to be completed. Systems for assuring quality must be underpinned by the views of service users and stakeholders. A report should be developed annually that is available for CSCI and other interested people that shows how the home has developed, and what still needs to be done to improve the quality of care. Timescale for action 01/06/06 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 YA1 YA17 YA35 Good Practice Recommendations To complete the revision to the statement of purpose. To revise the menus taking account of nutritional needs of service users. To offer alternatives on the written menu To develop equal opportunities and disability equality training into the staff training programme. Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westcliff House DS0000003801.V270443.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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