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Inspection on 10/01/06 for Westcotes Rest Home

Also see our care home review for Westcotes Rest Home for more information

This inspection was carried out on 10th January 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to provide a homely environment for residents and good relationships were observed between residents and staff members. Residents once again praised the food in the home and were particularly complimentary about the Christmas dinner. A good selection of activities is provided including outside entertainers and there are opportunities for residents to go shopping with staff should they wish to.

What has improved since the last inspection?

The identified staff member has received guidance on the use of appropriate language in care records and appropriate recording appeared in all records examined. The identified resident`s carpet has been re-fitted so that it no longer constitutes a tripping risk.

What the care home could do better:

The management responsibilities of the senior carer need clarifying to ensure that accountability is clear and that the home continues to be well run. A formal system of supervision for staff members still needs implementing together with a system to maintain and improve quality in the home based on consultation with residents and other interested parties. Some revision is needed of staff members` and managers understanding and knowledge of policies and guidance relating to adult protection to ensure the continued protection of residents.

CARE HOMES FOR OLDER PEOPLE Westcotes Rest Home 113-115 Hinckley Road Leicester Leicestershire LE3 0TF Lead Inspector Ruth Wood Unannounced Inspection 10th January 2006 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 Westcotes Rest Home DS0000006416.V276465.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 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. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westcotes Rest Home Address 113-115 Hinckley Road Leicester Leicestershire LE3 0TF 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) 0116 233 2919 Mr Les Downing Mrs Downing Mr Les Downing Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To be able to admit the person of Category MD named in variation application number 34009 dated 4th July 2002. 4th October 2006 Date of last inspection Brief Description of the Service: Westcotes Rest Home is located on Hinckley Road close to shops, public houses and bus routes to the centre of Leicester. The home offers a service to 20 older people in a spacious Victorian building. There are three lounges and one dining room located on the ground floor of the home. The majority of the home’s bedrooms are located on the first and second floors, accessible either by passenger lift or stairs. There is a paved courtyard to the rear of the building with patio furniture and tubs of plants and flowers where some residents like to sit. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place on a weekday between 10am and 2.45pm. The senior staff member Lisa Haynes was present for the majority of the Inspection; residents’ financial records and staff recruitment records were examined with the Registered Provider/Manager Les Downing. Care plans were examined and discussion held with residents, the senior staff member and manager. Some areas of the home’s environment were inspected. The majority of key standards were inspected at the home’s previous Inspection at the beginning of October. At this Inspection five Requirements were made of which four have been met. A further five Requirements were made at this Inspection. What the service does well: What has improved since the last inspection? 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. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 6 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 Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 7 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): Standards of assessment were inspected at the previous Inspection; the home does not provide intermediate care. EVIDENCE: Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 8 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, Care plans accurately reflect residents’ needs. EVIDENCE: Three care plans were examined; all showed signs of regular review and contained details of personal care needs. The care plan of the resident identified at the previous inspection had been updated appropriately as required. The risk assessment documentation for one resident requires updating but appropriate measures have been taken to minimise the identified risk. Daily records were detailed and written in appropriate language; one staff member has received guidance in this area as required at the previous Inspection. Aspects of health care were discussed relating to some of the home’s residents who are becoming increasingly frail. It was recommended that the senior carer discuss additional training for staff members in pressure area care and request that the district nurse review one resident’s long term use of cot sides. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 9 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): 12,13,14 Residents’ social, cultural and religious needs are met, they can exercise choice in their daily lives and they are supported in maintaining contact with family and friends. EVIDENCE: Residents are offered choice in relation to food, times to get up and go to bed and whether they participate in the social activities offered. Many residents bring items of personal property into the home. Visitors are welcomed at any time and there is sufficient communal space for residents to meet with visitors in private. One resident said that they had someone coming to see them at the home most days. Residents spoke about the activities that had taken place over Christmas; these had included a magician and a musical entertainer. Some residents had also gone to see the Christmas lights in town. Several residents commented on how much they had enjoyed their Christmas dinner. The senior carer commented that although residents had enjoyed Christmas they seemed to be ‘tired’ at the moment so no formal activities had been planned during January. A communion service takes place once per month in the home. One resident said that friends took them to church every week; another resident said that they would like to attend church if the home could arrange this. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 10 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): 16,18 There is an effective complaints procedure in place; some improvement is needed in the understanding of protection of vulnerable adults’ guidance to ensure that residents continue to be well protected. EVIDENCE: The Complaints Procedure is clearly displayed on the notice board in the entrance area and a Summary of the Procedure is contained within the Service Users’ Guide. Discussion with residents and with the senior staff member indicated that residents and relatives could raise concerns and these would be responded to appropriately. Several staff have received training in the recognition of abuse and there are policies in place covering all aspects of adult protection including whistle blowing. The senior staff member was unsure as to the detail of some of these policies and felt that this may the experience of other staff members. The Registered Provider and staff with management responsibility should develop awareness of the Department of Health’s current Guidance on the Protection of Vulnerable Adults in residential homes. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 11 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 Residents live in a comfortable, well-maintained environment. EVIDENCE: All communal areas visited were comfortably furnished, and there were no obvious maintenance issues. The carpet in the identified resident’s room has been refitted (as required at the previous inspection) and it no longer presents a tripping risk. Work to comply with recommendations from the environmental health officer is within the timescales allowed. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 12 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): 29 Residents are supported and protected by recruitment policy and practices. EVIDENCE: Staff recruitment records were examined. All prospective staff complete a standard application form, which contains full personal and work experience details. Verbal references are requested initially and then two written references. Criminal Records Bureau checks are undertaken before staff members are employed. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 13 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): 31,33,35,36 Management responsibilities should be clarified and a system of quality assurance instigated to ensure that the home continues to be effectively run. EVIDENCE: A senior staff member is taking on increasing management responsibility in the home and has been the key link person during the two most recent inspections. Her position and responsibilities in relation to that of the current registered manager (who is also the Registered Provider) needs clarifying/formalising. There is no formal system of quality assurance in place although the Senior Carer has stated that she is looking towards modifying the care planning system and reviewing some of the home’s policies. Several residents are supported in managing their finances; the home keeps full records of transactions in relation to these. Residents’ financial records were examined. There were some inaccuracies in the recording of some figures but these were easily identified and the source of the error quickly Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 14 identified by reference to staff members and other supporting records. The system in place therefore seems sufficiently robust. Staff are still not receiving one to one supervision on a regular basis as required at the previous inspection. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 15 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X X Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 13 Requirement The risk assessment undertaken for the identified resident must be clearly documented. The Registered Person must ensure that all staff are fully aware of the home’s adult protection policies. The Registered Person must ensure he and appropriate staff are aware of the Department of Health’s Guidance concerning the Protection of Vulnerable Adults and that it is followed. The management arrangements within the home must be clarified and the CSCI informed of the outcome. A system of internal monitoring within the home that involves regular consultation with service users and other interested parties must be developed. The Registered Person must ensure that a formal system of staff supervision is implemented within the home. (Previous timescale of 30/11/05 not met) DS0000006416.V276465.R01.S.doc Timescale for action 31/01/06 2. OP18 13 17/02/05 3. OP18 13 17/02/06 4. OP31 9 10/02/06 5. OP33 24 28/02/05 6 OP36 18 17/02/06 Westcotes Rest Home Version 5.1 Page 17 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 OP7 OP8 OP8 Good Practice Recommendations It is recommended that the senior staff members undertake a course in risk assessment It is recommended that additional training in pressure area care be sought for care staff. It is recommended that advice be sought from the District Nurse about one resident’s long-term use of cot sides. Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Westcotes Rest Home DS0000006416.V276465.R01.S.doc Version 5.1 Page 19 - 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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