CARE HOMES FOR OLDER PEOPLE
Westcotes Rest Home 113-115 Hinckley Road Leicester Leicestershire LE3 0TF Lead Inspector
Ruth Wood Unannounced Inspection 4th October 2005 10:00
04/10/05 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.V254886.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. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 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.V254886.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To be able admit the person of Category MD named in variation application number 34009 dated 4th July 2002. 15th December 2004 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.V254886.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Inspection took place on a weekday morning between 9.30am and 1.30pm. Planning for the inspection took approximately 1 & half hours and included a review of the Pre- Inspection Documentation returned by the Provider and the 9 resident and 5 relative Comment Cards. Recent notifications from the home were also reviewed. Discussion was held with the senior staff member and seven residents. Residents’ care plans and assessments were examined together with medication, fire and other records. Staff interaction and practice was indirectly observed. 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
Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Westcotes Rest Home DS0000006416.V254886.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 Westcotes Rest Home DS0000006416.V254886.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): 3 Good systems of assessment ensure that residents’ needs are met. EVIDENCE: Three residents’ files were examined; each contained a copy of the home’s assessment covering all aspects of care including physical, emotional and communication needs. Where possible the senior staff member had visited residents at home (or hospital) to ensure that Westcotes was able to meet their needs. A copy of the social worker’s comprehensive assessment was also on file. The senior staff member demonstrated a good understanding of residents’ needs and aspects of these were later confirmed during discussion with residents themselves. Westcotes Rest Home DS0000006416.V254886.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): 7,8,9,10 Residents are treated with dignity and respect and their health care needs are well met. Some improvement is required in aspects of residents’ care plans. EVIDENCE: The three care plans examined showed evidence of regular review and detailed care needs. Discussion about the needs of one of the residents indicated that a risk assessment had been undertaken with regards to aspects of their safety. The senior care staff member was clear as to how and why this process had been undertaken but this information was not clearly documented. The majority of daily records were detailed and written in appropriate language however one entry indicated that training was required for one staff member in record keeping and their understanding of aspects of the medication policy. Documentary evidence was in place showing that residents have access to dental, optical and chiropody services. Residents also have access to specialist health care services (such as consultant psychiatrists) and are well supported by the District Nursing service. A staff member will accompany residents attending hospital whether for emergency or routine appointments. Medication records examined were up to date and accurate and medication was stored appropriately. It is recommended that the date when prescribed creams or lotions are opened be written on the container to ensure that they are not used beyond their effective period.
Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 10 Staff were observed to address residents in a respectful manner. Of the nine residents who returned Comment Cards, six felt their privacy was always respected while three felt it was sometimes respected. All respondents said they felt well treated by staff. Westcotes Rest Home DS0000006416.V254886.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): 15 Residents enjoy well-balanced and appetising food served in pleasant surroundings. EVIDENCE: Menus showed a good balance of food was served with a choice available at all meals. Lunch on the day of inspection was homemade shepherds pie with fresh carrots and cabbage – this looked and smelled appetising. Residents were very complimentary about the food; all nine who returned Comment Cards said that they liked it and others added that the food was “always well cooked.” Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 12 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 Residents and relatives are aware of and express confidence in the Complaints Procedure. 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. Eight of the nine residents who returned Comment Cards stated that they knew who to speak to if they were unhappy with their care. Four of the five relatives who returned Comment Cares said they were aware of the Complaints Procedure; no resident or relative had needed to make a Complaint. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 13 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): 19,20,23,26 Residents live in a comfortable, well-maintained environment, which is clean and hygienic. EVIDENCE: Several bedrooms have been redecorated and had new carpets fitted since the previous inspection. One of these carpets requires adjusting, as it may constitute a tripping risk. The home is working on requirements and recommendations made by the environmental health officer and have recently re-tiled the kitchen. Two residents were enjoying the autumn sun in the courtyard, which was attractively decorated with planters. All areas of the home were clean and tidy and several staff have completed formal infection control training. Disposable gloves and aprons are routinely used when undertaking residents’ personal care. It is recommended that wipe clean surfaces be considered for all bathing and toilet areas rather than carpets. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 14 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): 27,28,30 There are sufficient competent staff to meet residents’ needs. EVIDENCE: Rotas show that there are generally four staff on duty for the morning shift and three staff in the afternoon. There is one waking night and one sleep in staff. Care staff are also responsible for all cooking and cleaning. The five relatives who submitted Comment Cards felt that there were always sufficient staff on duty. Three care staff have a National Vocational Qualification at level 2 and one has level 3. Two care staff are currently undertaking level 2 awards. All staff have undertaken training in moving and handling, fire safety, first aid and food hygiene. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 15 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): 36,38 The home’s policies and practices ensure the safety of residents but staff supervision requires some improvement. EVIDENCE: All care staff are involved in the preparation and serving of food and all have received training in food hygiene with certificates being clearly displayed. The majority of staff have first aid training with at least one ‘first aider’ on duty. All staff have received training in moving and handling and this is updated annually. Fire Records were examined; a comprehensive fire risk assessment was in place and there was documentary evidence that equipment and systems were regularly tested. A visit from the fire officer on 12/04/05 found arrangements in the home to be satisfactory. Documentary evidence showed that gas and electrical systems are checked annually. Staff are currently not receiving formal one to one supervision on a regular basis although there is an appraisal system in place. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 16 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 3 Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 17 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 2 Standard OP7 OP7 Regulation 13 17 Requirement All risk assessments must contain sufficient detail and be clearly documented. The Registered Person must ensure that all staff members are aware of the appropriate way to record residents’ information. The Registered Person must ensure that all staff members are aware of protocols with regards to administering medication. The Registered Person must ensure that the carpet in the identified room does not represent a tripping hazard. The Registered Person must ensure that a formal system of staff supervision is implemented within the home. Timescale for action 30/11/05 28/10/05 3 OP7 17 28/10/05 4 OP19 23 07/10/05 5 OP36 17 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 18 No. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations It is recommended that the senior staff members undertake a course in risk assessment It is recommended that the date when prescribed creams or lotions are opened be written on the jar or bottle to ensure that they are not used beyond their effective period. It is recommended that wipe clean surfaces be considered for bathing and toilet areas rather than carpets 3 OP26 Westcotes Rest Home DS0000006416.V254886.R01.S.doc Version 5.0 Page 19 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
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