Inspection on 04/08/05 for Westcott House

This inspection was carried out on 4th August 2005.

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.

Other inspections for this house

Westcott House 18/12/06

Westcott House 11/01/06

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 RH4 3QD Lead Inspector Catherine Campbell-Ace Unannounced 4 August 2005 10:00 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 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 H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westcott House Address Guildford Road, Westcott, Dorking, Surrey, RH4 3QD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01306 881421 Mr Y Charalambous Mr Edwardo Delacruz CRH Care Home 53 Category(ies) of DE(E) Dementia - Over 65, 51 registration, with number MD(E) Mental Disorder - Over 65, 51 of places OP Old Age, 9 Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 53 residents accommodated up to 51 may be in categories MD(E) or DE(E), and up to 9 may be in the category OP. 2. The age of persons accommodated will be over 65. 3. Up to 2 beds may be used for respite care. 4. 1 (one) service user is under 65 (MD) for which a condition is agreed. 5. 1 (one) service user is under 60 (MD) for which a condition is agreed. Date of last inspection 14 January 2005 Brief Description of the Service: Westcott House, which 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 ensuite facilities, and 7 shared rooms, of which 4 have ensuite 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 H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted 6 hours. The inspectors were Mrs Catherine CampbellAce and Mrs Janet Daulton. The registered provider, service users and staff assisted the inspectors who were made very welcome during the inspection. Care plans, daily records, employment files, complaints book and policies were viewed. The inspectors spoke to service users and staff. One service user said that he was very happy at the home and that the staff were very nice. Staff stated that the home had improved greatly in the last two months and they enjoyed working at Westcott House. The registered provider told the inspectors that she was spending more time at Westcott House and had made improvements in the home and is now supporting the registered manager. What the service does well: Service users were smart in appearance and some were wearing clothes that they had bought in a clothes sale at the home the day before. Drinks were readily available and staff were observed to be near service users at all times to attend to their needs. Staff were observed to be patient and kind to service users. It was noticed that they assisted service users professionally and patiently when eating their meals. The home’s activities are varied and service user appropriate. Service users were observed walking around the grounds accompanied by staff. The provider stated that service users had recently enjoyed an outing to the local pub for a drink, escorted by staff. Old time music hall had been arranged for service users on the day of inspection. One service user said that the food was very good. One relative spoken to said that since his mother had been admitted to Westcott house, her condition had greatly improved and he was very pleased with the care given. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home offers a high standard of care and support to service users. The home intends to continue to improve facilities. Requirements were made from this inspection and are as follows: • • • • • • • • Care plans require updating and must reflect the actual condition of the service user. The Complaints Procedure must be displayed for service users and families. Care plans must be kept securely. Service users equipment must be maintained at regular intervals The sluice in the main house is to be repaired. All documentation as detailed in paragraph 1-6 in Schedule 2 of The Care Homes Regulations is obtained on all staff. The home must devise a business plan. The stale odour noted must be eliminated. A recommendation was made for the Medication Administration Records to be made clearer. Copies of original blank MAR forms were difficult to read and record accurately. Original blank MAR forms would be easier for staff to read. Please contact the provider for advice of actions taken in response to this Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 9 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 standard(s) 2,3 Each service user has a written contract, which includes statement of terms and conditions of the home. Service users needs are assessed prior to moving into the home. EVIDENCE: Service users contracts were viewed and contained information on rooms to be occupied, care and services, fees payable and by whom, additional services, rights and obligations of service users and terms and conditions of occupancy. Viewing care plans evidenced that a thorough assessment of needs was carried out before admission. The provider informed the inspectors that service users were assessed either in hospital or at their own homes. It was evidenced that the care plan contained a plan for daily living and longer - term outcomes. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 10 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 standard(s) 7,8,9 There is clear care planning in place, however, care plans sampled did not reflect the actual condition of service users and were in need of updating. The systems for administrating medication were good, although the Medicine Administration Forms were difficult to read. EVIDENCE: Care plans were evidenced to be clear and concise. They contained sleep routines, activities of daily living, nutrition and manual handling risk assessments. Information regarding manual handling was displayed discreetly in service user’s bedrooms. The provider stated that one of the new practices she had implemented since June this year was to allocate staff to check service users wear their spectacles and these were clean and in good condition. The same practice applied to service user’s dentures. Care plans inspected were in need of updating, for example, one care plan sampled did not contain up to date information of treatment for pressure sores. When a staff member was asked about the service user’s condition she was unable to give accurate information about the state or treatment of the service user’s wounds. Care plans evidenced were in need of updating. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 11 Service users were visited regularly by the General Practitioner. Eyesight tests were carried out yearly. Care plans were observed not to be kept securely, as the filing cabinet in which the care plans were kept was unlocked. A requirement made to keep care plans in a secure place. A recommendation was made that the manager ensures that the General Practitioner supplies the home with original MAR sheets. At present the home is supplied with MAR sheets photocopied, with the prescribing medication adhered to the side of the MAR sheet on printed out labels. The MAR sheets were difficult to read and poorly copied. The Medication Policy and Procedure was evidenced, together with samples of signatures of those who administer medication. No service user self - administered medication and no service user received Controlled Drugs. All medication was observed to be stored correctly. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 12 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 standard(s) 12,15 Service users are provided with a range of activities which reflect their individual needs and preferences. The home offers choice within a well balanced diet. EVIDENCE: Service users were offered various activities in the home, for example, one service user said that he had a party for his 99th birthday and was looking forward to going to his sister’s home for her 102nd birthday. Staff were very enthusiastic about the activities they had arranged for service users; one activity was a trip to the local pub for a meal. The registered provider stated that the trip was so successful that the next time an outing had been arranged which was a walk to the village, service users who had been on the previous outing to the pub wanted to go in to the pub again! A barbecue is arranged in the near future and old time music hall was being held on the day of inspection. It was evidenced that exercise classes for service users is held weekly, reminiscence sessions were held regularly and the inspector was told that bingo, with prizes was very popular with service users. Staff were observed to be escorting service users walking in the grounds, and it was pleasing to see service users being free to walk in the grounds and being free to express their personality. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 13 An outing is planned for service users to go to Littlehampton in the near future. Service users said that the food was good. Mealtime was observed, and staff assisting service users in eating their meals did so professionally and patiently, affording the service users dignity in this process. Service users were given a choice of two main meals and could have an alternative if the choice was not to their liking. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 14 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 standard(s) 16 The home has a Complaints Policy, however it was observed that the Complaints Policy was not available for service users or relatives. EVIDENCE: The Complaints Policy and Procedure was viewed. Service users, when asked, did not know of a complaints policy but knew to whom they could complain if they so wished. Service users and families spoken to were very complimentary of the home and stated that they had no complaints, only praise for the home. Staff interviewed said that they knew who to go to if they had a complaint, and their concerns were dealt with promptly. The complaints procedure was displayed in the information guide and contained the telephone number and address of The Commission for Social Care Inspection. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 15 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 standard(s) 19,26 The home continues to offer a homely environment for service users, however a stale odour was noted during inspection of the premises. EVIDENCE: The home is attractive with a large entrance hall and several lounges for service users to use. A conservatory is placed between the main home and annexe, which is used for activities for service users. The communal rooms were observed to be clean, comfortable and bright. A stale odour was noted in the main hallway and the provider assured the inspectors that the cause was the carpets in the hallway, which were due to be renewed in the near future. Some furnishings and flooring had been renewed, and three baths had been removed and replaced by showers. The home was in good decorative order with decoration of the outside taking place on the day of inspection. A sluice machine was in need of repair, which the inspectors were assured would be repaired immediately. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 16 The gardens were accessible and secure for service users and at the time of inspection service users were walking freely in the grounds, some accompanied by staff. Others were sitting in comfortable chairs in the shade. Whilst the inspectors were inspecting the premises they found a wheelchair, which was in need of repair. The wheelchair was removed from the area immediately. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The home has a written recruitment policy, however, employment files inspected were not complete. Records of induction did not exist and therefore could not confirm safe practices were followed. EVIDENCE: Employment files were evidenced and contained application forms, work permits, contracts of employment and references. One staff file did not have a second reference and two staff members had not had Criminal Record Bureau checks made. The provider assured the inspectors that the CRBs had been sent for and that these staff were not working unsupervised. Staff training had been arranged, with a new training plan in place which includes Dementia training, Food hygiene, Manual handling and Assisting Service Users To Eat. The provider is an NVQ assessor and the home has 10 staff who have achieved NVQ awards. The provider is at present working towards a Master’s Degree in Dementia. There was no evidence that new staff received induction and no foundation course training had been arranged. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Standards 33,35 and 38 were not examined at this inspection Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x x Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 20 yes 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 7 Regulation 17 Requirement All care plans must be regularly reviewed and must reflect the actual condition of the service user. The sluice in the main house must be repaired. The registered person must ensure that all documentation as detailed in paragraph 1-6 in Schedule 2 of The Care Homes Regulations is obtained on all staff working in the home. This is an outstanding requirement from the last 2 inspections, that all documentation is complete. failure to comply may result in legal advice being sought. The business and financial plan for the establishment must be available for inspection. This is an outstanding requirement from the last 2 inspections, that a business and financial plan must be made. The care plans must be kept securely. The stale odour must be eliminated. The Complaints Procedure must be displayed and be accessible to service users and families. H58_s13368_Westcott House_v222808_260405 stage 2.doc Timescale for action 04/10/ 05 2. 3. 26 29 13 19 04/09/05 .04/09/05 4. 34 25 04/09/05 5. 6. 7. 37 26 16 17 16 22 04/09/05 04/09/05 04/09/05 Westcott House Version 1.30 Page 21 8. 22 23 Equipment must be regularly maintained. 04/09/05 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. Refer to Standard 9 Good Practice Recommendations It is strongly recommended that the registered manager ensures that the General Practitioner provides the home with original Medication Administration Record sheets to improve the accuracy of recording medication administered to service users. Westcott House H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 H58_s13368_Westcott House_v222808_260405 stage 2.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!