CARE HOMES FOR OLDER PEOPLE
Westcliffe Care Home Westcliffe Country House 78 Shelford Road Radcliffe-on-Trent Nottingham NG12 1AW Lead Inspector
Karmon Hawley Unannounced Inspection 29th September 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Westcliffe Care Home Address Westcliffe Country House 78 Shelford Road Radcliffe-on-Trent Nottingham NG12 1AW 0115 9335 197 0115 9110089 vanceowen@fiskertonvcb.net Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Vance Lloyd Garnet Owen Mrs Beverley Owen Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15/02/05 Brief Description of the Service: Westcliffe is a converted and extended period house set in the pleasant village of Radcliffe on Trent and is near to local amenities and is set in well-maintained grounds. The conversion has been sympathetic to the character of the building and the home is decorated to a satisfactory standard and provides a welcoming, homely feel for service users and visitors. Radcliffe on Trent is supported by rail, bus and road networks. The home provides care for nineteen older people with personal care needs in single and double rooms, some with ensuite. There is a large dining, seating area and a conservatory sitting room. The grounds to the rear of the property are inviting, well kept and accessible. There is a passenger lift and levelled areas throughout the home to enable access for service users with disabilities. Within one area of the home there are steps due to the nature of the house, therefore mobile service users occupy this part of the home. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day during which three service users care notes, three staff personnel files and other documentation related to the care and environment were inspected. Time was spent with both proprietors, staff and service users in discussion with regards to the home. Five service users and one relative were spoken with and all spoke very highly of the home, care received and the staff. Three staff were spoke with and were able to discuss the core values and principles. What the service does well: What has improved since the last inspection?
There have been several improvement made since the last inspection and all the requirements set have been met. The roof has been repaired and service users rooms decorated to ensure a continued well-maintained environment. Liaison had taken place with the fire officer with regards to propping open doors; this is no longer practice thus ensuring service user safety. The infection control policy had been updated, again further protecting service users and ensuring safety. An additional extension has been added off the reception area to provide a more central office for the managers and a private room for consultations for service users should it be required. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Information required to make an informed choice is available and service users can be assured a written contract and statement of terms and conditions will be received. Whilst preadmission assessments take place, the format in use requires updating to ensure service users needs are fully assessed and met. EVIDENCE: The statement of purpose contained all the required information and was presented in an easy to read format. The terms and conditions of admission were clear and ensured service statutory rights are not contravened. The managers’ within the community and also within the home carry out preadmission assessments. The preadmission assessment in use was of an older format and whilst it included the daily activities of living it did not cover all the requirements of standard 3. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 Service users health, personal and social care needs are set out in an individual plan of care, however information available is brief and may not fully reflect needs. Service users may be placed at a degree of risk due to the lack of individual risk assessments. Service users health care needs are fully met. EVIDENCE: Three service users case files examined demonstrated that these were of a personalised and individual nature. A key worker system is in place and reviews are carried out periodically. An assessment with regards to the activities of daily living is carried out to ascertain service users needs and within two case files examined a falls risk assessment and manual-handling assessment had taken place. However information available within care plans was brief and did not fully identify care requirements of complex needs. Within two service users files where a highlighted problem was diabetes mellitus a risk assessment was not in place with this regard. One service user who had been noted to get her leg trapped in a bedrail did not have a risk assessment in place with regards to this. Progress notes were not maintained on a daily basis, however significant events were noted.
Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 10 There was evidence available within service users case notes to demonstrate that relevant services are accessed with regards to health care needs. Services are accessed within the local community if required and specialists also visit the home. The manager stated there was a good rapport with the district nursing team who ensures service users receive appropriate assessments and equipment as required. Service users spoken with stated that they received these services. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15 Service users are enabled to maintain contact with relevant others and the community as they wish. A wholesome, appealing and balanced diet is available however further consideration is required to hazard analysis and the requirements set by the environmental health officer to fully ensure service users well being. EVIDENCE: The manager stated that there are no restrictions on visiting times, the main doors are locked early morning and late at night therefore relatives would need to use the bell to gain access. Service users are able to receive visitors in private if required and may choose who they wish to see. Service users when spoken with stated that they receive visitors at all times and also go out with relatives. One relative spoken with stated that he is always made welcome when he visits. The menu on offer was observed and demonstrated that a wholesome, appealing and balance diet is available. Whilst a specific choice is not offered at the main meal, alternatives are available if required; service users spoken with were able to substantiate this. Service users stated that meals were very good and plentiful. The environmental health officer visited the home recently and two requirements and several recommendations were made, which the manager is working towards. Records observed were up to date and complied with requirements, however hazard analysis of critical control points were not available.
Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 12 Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and their relatives can be assured complaints will be listened to, taken seriously and acted upon. EVIDENCE: There have been no complaints received since the last inspection. A satisfactory policy was in place with regards to this. Staff when spoken with were able to discuss how they would deal with a complaint should it be received. Service users and the relative spoken with spoke highly of the staff, care received and voiced no complaints. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users live in a safe and satisfactorily maintained environment. EVIDENCE: A maintenance plan is in place and there was evidence that this is being worked towards. The home’s roof has been repaired and service users rooms have been decorated. An extension has been added onto the reception area so the manager’s office can be more central and an additional private room is available for service users and consultations. The manager has liaised with the fire officer with regards to door being propped open and this practice has now ceased. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 The numbers and skill mix of staff meets service users needs and they are supported and protected by the homes recruitment polices and practices. EVIDENCE: The duty rota was observed and demonstrated that sufficient staff were employed and available throughout the day. The manger considers skill mix and experience when planning the duty rota and an on call system is also used. Staff spoken with stated there was sufficient staff available to meet service users needs, service users spoken with substantiated this. Three staff files were observed and demonstrated that all required documentation was in place. All staff have signed to state that they have received the General Social Care Council Code of Conduct. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Service users health, safety and welfare is promoted and protected, however this may be compromised due to the lack of individual risk assessments and routine fire alarm testing. EVIDENCE: All maintenance and servicing checks were observed and were satisfactory. Risk assessments are in place with regards to service users, staff, visitors, the environment and fire, however individual service users files did not contain all the required risk assessments. Staff undertake training in health and safety and related issues and an induction programme is in place. Fire alarm testing was noted not to be carried out on a weekly basis. Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation Requirement Timescale for action 30/12/05 2 OP7 3 OP7 4 OP15 5 OP38 14(1a,c,d) The responsible individual is required to ensure service users undergo appropriate preadmission assessments prior to entering the home to ensure their needs can be fully met. 15(1) The responsible individual is required to ensure care plans provide sufficient information to ensure needs are fully addressed and met. 13(4,c) The responsible individual is required to ensure appropriate risk assessments are in place to fully protect service users. 16(2,g) The responsible individual is required to liaise with the environmental health officer with regards to hazard analysis critical control points. 23(4,c) The responsible person is required to ensure fire alarm systems are tested weekly. 01/11/01 01/11/01 30/12/05 01/11/05 Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westcliffe Care Home DS0000008819.V251391.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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