Inspection on 11/01/06 for Westcott House

This inspection was carried out on 11th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Westcott House 18/12/06

Westcott House 04/08/05

Westcott House 14/01/05

Westcott House 31/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Westcott House Guildford Road Westcott Dorking Surrey RH4 3QD Lead Inspector Mary Williamson Unannounced Inspection 11th 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 Westcott House DS0000013368.V276432.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. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westcott House Address Guildford Road Westcott Dorking Surrey RH4 3QD 01306 881421 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 Y Charalambous Mrs Julie Ann Charalambous Care Home 53 Category(ies) of Dementia - over 65 years of age (51), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (51), Old age, not falling within any other category (9) Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The age range of persons accommodated will be over 65. Up to 2 beds may be used for respite care Of the 53 residents accommodated up to 51 may be in the categories MD(E) or DE(E), and up to 9 may be in the category OP 2 (Two) service users are under 65 (MD) for which a condition is agreed. 1 (one) service user is under 60 (MD) for which a condition is agreed. Date of last inspection 4th August 2005 Brief Description of the Service: Westcott House, is registered to provide nursing care for up to 53 older people is located in the village of Westcott, which is in close proximity to the town of Dorking. The home is a large property situated in its own grounds. The home consists of the main house and an adjoining annexe. There are a total of 39 single bedrooms, 35 of these having en-suite facilities, and 7 shared rooms, of which 4 have en-suite facilities. There are communal areas consisting of lounges and a separate dining area. A large conservatory in between the main building and annexe is used for activities. A passenger lift provides access to all floors. The gardens are spacious with patio areas. All parts of the property are accessible for wheelchairs. Car parking is available in the grounds of the property. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the second in The Commission for Social Care Inspection programme year 2005/2006. Mary Williamson who is the Lead Inspector for the service undertook the inspection. The Provider Mrs Charalambous was present throughout the inspection, together with the Registered Manager Mr Edwardo Delacruz, for part of the inspection. A tour of the premises was undertaken and records relation to the care of the service users and the management of the home were examined. Several of the service users were spoken to more in more detail then others. It was also possible to talk with several staff on duty. Lunch was observed being served in the annex. There was also an Environmental Health Inspector visiting the home during the inspection. The inspector would like to thank the service users the staff and the management team for their positive contribution to the inspection process. What the service does well: The home provides care and accommodation for service users with complex mental health needs. The staff on duty had a good understanding of the assessed needs of the service users in their care, and were interacting in a kind and patient manner with them. The service users were well groomed and the service users being nursed in bed were well cared for and comfortable. Sensitive support was offered to service users who required help with feeding. The provider is investing a lot of time updating all the required documentation in the home. All the staff recruitment files have been updated and all the required documentation is in place. As a result of this exercise the home has embarked on a recruitment drive as several staff left employment. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 6 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. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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 Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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, and 5 Prospective service and their relatives have appropriate information available to help them make a choice about living at the home. Needs assessments and contracts are in place. EVIDENCE: All prospective service users and their relatives are given a welcome pack on admission, which includes a service user guide and statement of purpose. This also included the homes complaints procedure. All prospective service users have a pre admission needs assessment undertaken by the manager or the provider prior to admission. This will determine if the home can meet to needs of the prospective service user. Trial visits are encouraged whenever possible, however in most cases the relatives or the funding authorities visit the home on the service users behalf. Individual contracts of occupancy are in place. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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, and 10. Appropriate arrangements are in place to meet service users health care needs with dignity and respect, as outlined in individual care plans. The medication administration policy in place protects the service user sin the home. EVIDENCE: Individual care plans are in place. Several care plans were sampled during the inspection. These are generally well maintained with personal care needs documented. However some required more detail with regard to emotional, and social care needs. Others remained unsigned. Risk assessments are included in care plans for moving and handling, nutrition, the use of cot sides on beds, and the Waterlow score for skin care. All the service users are registered with a local GP. There was a locum GP visiting the home during the inspection, as several service users were unwell with chest infections. She was very supportive and understanding of the needs of the service users. Arrangements are also in place for service users to see a dentist, chiropodist and optician on a regular basis. There is also input from the psychiatrist with regard to behaviour problems and medication reviews. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 10 The home has a policy in place for the administration of medication. The home also adheres to the Nursing and Midwifery Council Code of Conduct in relation to the administration of medication. Boots the chemist now supplies all the medication to the home in blister pack form. The medication recording charts were seen and are well maintained. All medication is stored correctly and the fridge used to store medication is well maintained and the temperature recorded regularly. All staff who administer medication have regular medication update training. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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): 12, 13, and 15. Service users are provided with a range of activities, which reflect their individual and collective needs and preferences. The nutritional needs of service user are met. EVIDENCE: There is a programme of activities in place, which offers service users variety and choice. Music and movement and gentle exercise are offered twice weekly. Some service users enjoy a daily newspaper, and others benefit from a one to one listening or talking session. Reminiscence groups are also provided and some service user like bingo sessions, card games and board games. Staff were observed engaging in some of these activities throughout the inspection. Special events are celebrated for example birthdays and anniversaries. Family links are maintained and visitors are welcome in the home at any reasonable time. Relatives are also included in the care planning process. Spiritual needs are supported and visits from various clergy are encouraged. The careering arrangements in the home are satisfactory. The chef plans the menus with input from service users and staff team. The menus are well balanced and nutritious. Lunch was observed being served in the annex. This was served from a hot trolley by the chef. There was a choice of main course, which was chicken wrapped in bacon, or roast lamb, both served with a selection of vegetables roast or mashed potatoes. Strawberry mouse for Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 12 desert followed this. Seven service users in the annex required assistance with feeding which was offered in a sensitive manner by the staff on duty. The kitchen was not visited as there was an Environmental Health Inspection also taking place during this inspection. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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 and 18. The service users are protected by the complaints and the abuse awareness policies and procedures in the home. EVIDENCE: The complaints procedure is available to all service users and their relatives on admission to the home. This is included in the welcome pack. There have been no complaints recorded since the last inspection. The inspector observed several letters of thanks and compliments on display. There is a copy of Surrey’s Multi Agency Protection of Vulnerable Adults policies and procedures available in the home. The home also has an abuse awareness policy in place and all staff have training in this during induction. Staff when questioned were aware of these procedures. There is currently an investigation in progress under Surrey’s procedures regarding an allegation of abuse in the home. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 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, 20, 21, 22, 23, and 26. The location and layout of the home is suitable for its stated purpose. It is well maintained, safe and meets the individual and collective needs of the service users living at Westcott House. EVIDENCE: The home is a large property with accommodation arranged over three floors and an annex. On the day of the inspection the home was well maintained, comfortable and free from offensive odour. There are several large lounge areas and two dining rooms. These are well decorated, well furnished and comfortable. There is a conservatory situated between the main home and the annex, which is also used for activities for the service users. The provider stated that she has implemented an ongoing programme of refurbishment since she took up post in June 2005. A new wooden floor has been fitted in the entrance hall and the main dining room has been redecorated to include new curtains. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 15 There are ample bathrooms and toilets situated throughout the home. The home has been adapted to meet the mobility needs of the service users. Grab rails are situated in convenient places, toilet seats have been raised, assisted baths have been installed, electric hoists are provided in individual bedrooms and manual hoists are also in place. There is a shaft lift to access all floors, specialist beds are in use, call bells are provided in all rooms and ramps are in place to access the gardens. Thirty- nine service users are of single occupancy and there are seven shared rooms. Most of the rooms are en-suite and all are well decorated and comfortable. The bedrooms have been personalised to reflect individual personalities and interests. The home was clean and free from odour. The laundry is well equipped and the laundry assistant is aware of the home’s infection control policy. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 16 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, and 30 The staff duty rota was seen. The number and skill mix of staff on duty was sufficient to meet the assessed needs of the service users. Recruitment practice has improved since the last inspection. EVIDENCE: The staff duty rota was examined and indicated that there were sufficient staff on duty to meet the assessed needs of the service users. This included three qualified nurses, eight carers, two cleaners, one laundry assistant, one bed maker, one chef, one kitchen assistant, three maintenance persons, and a part time administration assistant on duty during the inspection. There is a recruitment procedure in place and the provider stated that much time and effort has been afforded to bring all the old documents up to date. The two most recent staff employment files were seen. These were well maintained and contained all the required documentation. The home’s staff training programme was discussed with the provider. There is an induction-training programme now in place since the last inspection and new staff files indicate that this training is in progress. One staff member on duty in the annex confirmed this. The provider stated that part of the business plan included the forthcoming NVQ training. Several staff have achieved NVQ level 2 but some have since left employment. There are four NVQ assessors on the staff team. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 17 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, 36, and 38. The service users live in a well managed home. The health and welfare of the service users are protected. EVIDENCE: The home has a registered manager who is a qualified nurse with a RMH qualification. He has worked in the home for sixteen years and has his NVQ Level 4 in management. The home has under gone major management restructuring since June 2005. The providers who used own two homes have now concentrated all their efforts into Westcott House. The provider and her former deputy are working in the home in a super nummary capacity to update policies and procedures, care plans and the staff-training programme. The home is managed in the beat interest of the service users and regular meetings take place to update service users and staff. Records of these meetings were seen. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 18 The provider continues to develop a wide range of health and safety policies and procedures in line with safe working practice. All staff have been trained in moving and handling, first aid, food hygiene, dementia awareness, and COSHH. The fire records were seen and are well maintained. All staff heve regular fire safety training. There is also a contract in place for the maintenance of the fire fighting equipment and emergency lighting. The accident records were seen and are well maintained. Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X 3 X 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 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17 Requirement All care plans must be regularly reviewed and must include social and emotional needs of service users. These plans must also be signed. Timescale for action 20/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Westcott House DS0000013368.V276432.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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