Inspection on 20/04/05 for Westcombe Park Nursing Home

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Westcombe Park Nursing Home 02/03/07

Westcombe Park Nursing Home 03/02/06

Westcombe Park Nursing Home 26/07/05

Westcombe Park Nursing Home 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

Care Home For Older People Westcombe Park Nursing Home 112 Westcombe Park Rd Blackheath London SE3 7RZ Unannounced Inspection 20 March 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Westcombe Park Nursing Home Address 112 Westcombe Park Rd, Blackheath, London, SE3 7RZ Email address Name of registered provider(s)/company (if applicable) BUPA Care Homes (Partnerships) Limited Name of registered manager (if applicable) Nicola Hills Type of registration Care Home No. of places registered (if applicable) 51 Tel No: 020 8293 9093 Fax No: 020 8858 2026 Category(ies) of registration, with (number of places) Old age, not falling within any other category (51) Registration number G010000227 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 12th November 2004 YES YES 19/7/04 If Yes refer to Part C Westcombe Park Nursing Home Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 20 March 2005 10:30 am R Blenkinsopp ID Code 096109 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Nicola Hills. Westcombe Park Nursing Home Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Westcombe Park Nursing Home Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Westcombe Park Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Westcombe Park Nursing Home Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Westcombe Park Nursing Home is located to the rear of a privately owned apartment block, which is managed by Goldsborough Estates. The home is sited on a residential road within walking distance of local shops and public transport links. Access to the front entrance of the Care Home is restricted to ambulances or vehicles collecting or dropping off visitors or service users. Parking is provided for visitors in front of the private apartments. Westcombe Park Nursing Home is registered to provide nursing care for 51 male or female service users, ten of whom can be aged 50 years and over and 41 of whom must be at least 60 years of age. Accommodation is provided on three floors. Each of the floors has a variety of bedrooms, forty-three of the rooms are single occupancy and three rooms are shared. Forty of the bedrooms have en-suite facilities. Each of the floors has a communal lounge, bathrooms and toilets. On the ground floor there is a dining room and a large lounge, which is used for activities. Kitchen and laundry facilities are provided on site. At the rear of the property service users have access to a shared garden. Westcombe Park Nursing Home Page 5 PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection was conducted as unannounced visit .The standards, which were assessed, were those, which were not at the last inspection. In addition progress on the previous requirements was monitored for compliance. The inspector met with staff and service users during the visit. The manager arrived during the course of the inspection and facilitated it thereafter. The information and observed practice indicated a good standard of care was provided. On the day of the inspection 43 service users were in the home. Currently only 49 beds are in use due to the review of two bedrooms. All of the previous requirements had been addressed. Arising out of this inspection was one requirement and two recommendations. Choice of Home (Standards 1-6). Within this section no standards were assessed on this occasion. Health and Personal Care (Standards 7-11). Two standards were assessed in this section relating to medication and health care. One requirement and one recommendation were made regarding medication records. Daily Life and Social Activities (Standards 12-15). Daily activities are as flexible as possible within the confines of communal living where some routines must be in place. Visiting is open and encouraged. A selection of activities are offered by way of group activities although service users have the choice whether they wish to participate. Complaints and Protection (Standards 16 – 18). The CSCI has received no complaints regarding this service. The three complaints investigated internally were actioned appropriately. Environment (Standards 19-26). The home was clean, tidy and odour free on the day of the inspection. Bedrooms were personalised and communal areas maintained in a homely manner. Staffing (Standards 27-30). Staffing levels are maintained as per the previously agreed staffing notice. The home uses agency and bank staff, in addition its own staff doing extra duties to provide cover. Management and Administration (Standards 31-38). The health and safety certificates were seen to be satisfactory. Training, supporting risk assessments and environmental standards were all in place to address health and safety matters in the home. Westcombe Park Nursing Home Page 6 Westcombe Park Nursing Home Page 7 Requirements from last Inspection visit fully actioned? If No please list below YES STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Staffing notice Met (Yes / No) YES. Westcombe Park Nursing Home Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No Regulation Standard * Requirement Timescale for action 1 OP13 9 The Registered Person must ensure all information in respect of medication is fully completed with initials or signatures in place. 30/4/05 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No Refer to Good Practice Recommendations Standard * The Registered Person should ensure that when hand transcriptions are used two staff sign the medication sheet to confirm the accuracy of the information recorded. The Registered Person should explore the use of independent advocates for those service users who want them 1 OP9 2 OP17 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10. Westcombe Park Nursing Home Page 9 PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO NO YES NO YES NO NO NO YES YES YES YES YES YES NO NO YES NO YES 4 0 0 NO NO YES YES 23 13 20/3/05 10.30 4.00 Westcombe Park Nursing Home Page 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Westcombe Park Nursing Home Page 11 Choice of Home The intended outcomes for the following set of standards are: • • • • • • 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. Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) 456.00 To (£) 950.00 Any charges for extras YES HAIRDRESSING, TIOLETRIES. 0 Standard met? If yes, please state what the extra’s are: Key findings/Evidence This standard had been previously assessed and met. Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Standard met? Westcombe Park Nursing Home Page 12 This standard had been previously assessed and met. Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not admit those service users requiring intermediate care. Westcombe Park Nursing Home Page 13 Health and Personal Care The intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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. Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X 1 3 Key findings/Evidence Standard met? The home records all accidents and incidents in a book, which is located in the office. Regulation 37 notifications are forwarded to the CSCI. The manager explained that she has established links with the “ Falls” clinic in Greenwich where service users may be referred. Staff are first aid trained, four of which have completed the four-day first aid course. The four staff are spread throughout day duty and night duty and within different disciplines. The home has a visiting G P service and other heath provision is provided through domiciliary visiting services, i.e. optician, dentist. Westcombe Park Nursing Home Page 14 Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The medication charts on the first floor were viewed. Records were in place for medications received and those returned. Service users photographs were in place and known allergies were recorded. The allergies were recorded although it would be preferable if this information was recorded on the actual medication administration chart in use. In some cases where hand transcriptions had been used, the medication received into the home had not been recorded. This information was in place on the printed medication sheets. Eye drops and prescribed powders had ticks in place as proof as application. Staff signatures/ initials must be in place. Full and comprehensive records must be place for all medication procedures. Please see requirement 1. Please see recommendation1. Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 15 Daily Life and Social Activities The intended outcomes for the following set of standards are: • • • • 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. Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? During the inspection it was evident that flexibility and choices were incorporated into the service user day. Service users were spending time either in the communal area or their own bedrooms. Some service users were reading others watching TV and visitors were in the home. There was a birthday celebration planned for the afternoon and preparations were under way for this. Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? Visiting is flexible at any reasonable time. The majority of visitors attend evenings and weekends. Visitors are routinely offered tea and if they wish may have a meal in the home. Many service users have family and friends who live locally. Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users have specific staff for each floor and identified key workers. The key worker has the responsibility of coordinating the service users care and involving family members where possible. Preferences and choices would be identified during the initial assessment period from which a care plan can be devised and any information obtained incorporated. Relatives are encouraged to be as involved with the care as they wish to be. Service users are involved in feed back questionnaires in respect of the care and services provided. Westcombe Park Nursing Home Page 16 Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? This standard had been previously assessed and met. However the lunch was seen and it was very nicely presented. Service users were seen to have choices in their main meal with a fruit plate offered after the main meal as well as, or instead of a dessert. The requirements relating to the fly screen at the kitchen window had been addressed. Foodstuffs in the kitchen were appropriately stored and served with supporting temperature records in place. Westcombe Park Nursing Home Page 17 Complaints and Protection The intended outcomes for the following set of standards are: • • • 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. Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure, which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 3 3 0 0 0 0 100 3 Key findings/Evidence Standard met? The complaints procedure was available and on display. The manager had investigated three complaints received internally all of which were substantiated. The supporting paperwork and investigation was retained .The CSCI have received no complaints regarding this service. One service user, with whom the inspector met, had complained on one occasion and the service user felt that she had been listened to and the complaint investigated appropriately. Westcombe Park Nursing Home Page 18 Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Service users are able to vote and postal voting is arranged for them to do so. Service users have next of kin who act on their behalf or in some cases solicitors. The inspector recommended that the home explore the introduction of independent advocates for those service users who require and wish to have the services of one. Please see recommendation 2. Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 0 0 Key findings/Evidence Standard met? Since the last inspection twelve staff have completed adult protection training with more training planned it is envisaged all staff will have completed the training. Staff with whom the inspector met confirmed that they received training internally and externally. Staff were aware of what constitutes abuse and what action to take. Westcombe Park Nursing Home Page 19 Environment The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home has sitting areas on each floor with a large dining area on the ground floor. On the first floor a “ Bar “ area had been developed with a reminiscence theme. Bottles relating to years gone by were on display. This area is open to service users and visitors on a weekly basis. This is something, which people enjoy. Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Currently there is one shower facility on the first floor, which is out of service. This is undergoing refurbishment and the area was locked to prevent access. The manager felt that this had not affected the service adversely due to the number of other bathing facilities in the home. Westcombe Park Nursing Home Page 20 Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 21 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO X X X X X X X X X X 3 Key findings/Evidence Standard met? The bedrooms viewed were personalised, clean and tidy. Many had individual items such as photographs, ornaments and some furniture. Several service users had their own TV’s and radios and preferred to spend time in their bedroom. Westcombe Park Nursing Home Page 22 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? The inspector saw several pieces of equipment in use appropriate to service users needs. Hoists, pressure relieving mattresses zimmer frames and walking sticks were all available. The storage areas for the equipment is limited and in one lounge equipment was stored in it, giving it a clinical feel. Storage the inspector was advised was at a premium. Alternative storage areas should be investigated to reduce the need to use communal areas as such. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 23 Staffing The intended outcomes for the following set of standards are: • • • • 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. Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 0 16 27 X No. staff hours allocated No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X Nursing X X X X 13 23 27 Standard met? 3 Westcombe Park Nursing Home Page 24 The home works within its staffing notice and above when needed. Agency staff are brought in when needed this was the case the morning of the inspection. Staff with whom the inspector met stated that the staffing levels were met although the agency staff did not always arrive on time, making the workloads heavy particularly during the morning shift. In the case of short-term sickness / absence this is inevitable that staff brought in at short notice may be late and thereafter need induction and supervision. Bank staff are also employed to address staff shortages. Some staff work above the hours recommended in the working time directive. The manager stated that she monitors staff hours very carefully and if any concerns are identified, then the hours would be reviewed. There was discussion regarding enrolled nurses on night duty taking charge on rare occasions. Information was given in respect of this and a written request should be forwarded to the Lead Inspector, Mr Keith Izzard. Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard had been previously assessed and met. X X Standard met? 0 Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 25 Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 26 Management and Administration The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 27 Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? The business plan as not seen although there were no shortfalls identified at this inspection. Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X 3 Key findings/Evidence Standard met? The inspector was advised that home retains no money for individual service users. All money is deposited into a bank account. Any money required would be obtained through petty cash and then invoiced to the individual’s own account. There is an individual statement for each service user. The central account is a non-interest account. The finances are audited every month. Standard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard had been previously assessed and met. Westcombe Park Nursing Home Page 28 Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The records requested were made available and maintained in an orderly manner. Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The inspector viewed a selection of health and safety records these were current. Staff training has been conducted in manual handling. Two staff are trained to cascade manual handling to all staff. All mandatatory training is provided. The weekly fire alarm record were completed. Fire service records indicated regular servicing. The home has two staff trained as fire officers. The general observation whilst touring the home was that health and safety measures were addressed correctly. Westcombe Park Nursing Home Page 29 PART C (where applicable) COMPLIANCE WITH CONDITIONS Condition Staffing Notice Comments Compliance YES Condition Comments Compliance Condition Comments Compliance Condition Comments Compliance Lead Inspector Second Inspector Regulation Manager Date Signature Signature Signature Westcombe Park Nursing Home Page 30 Public reports It should be noted that all CSCI inspection reports are public documents. Westcombe Park Nursing Home Page 31 PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 20/3/2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Westcombe Park Nursing Home Page 32 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YES Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate YES YES YES Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES Action plan was received at the point of publication YES Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YES NO NO Other: enter details here Westcombe Park Nursing Home Page 33 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Westcombe Park Nursing Home Page 34 Westcombe Park Nursing Home / 20 March 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000006775.V199509.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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