Inspection on 29/06/06 for Westcroft

This inspection was carried out on 29th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westcroft 11/02/09

Westcroft 12/02/08

Westcroft 04/09/07

Westcroft 24/03/06

Westcroft 02/09/05

Westcroft 21/02/05

Westcroft 27/07/04

Westcroft 10/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westcroft 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS Lead Inspector Mark Dunford Key Unannounced Inspection 09:45 29 & 30th June 2006 th 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 Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 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. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westcroft Address 1 Cleveland Walk Bath Bath & N E Somerset BA2 6JS 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) 01225 466685 01225 443367 Mrs Jean Uter Ms Pamela Anne Ramjutton Care Home with nursing 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate 21 Patients aged 50 years and over requiring nursing care Staffing Notice dated 03/10/1996 applies Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 24th March 2006 Brief Description of the Service: Westcroft Nursing Home is registered as a Care Home with nursing. It is situated in an elevated position in Bathwick, close to the city centre of Bath. The home is an older property with an extension set out over three floors. There are a mixture of single and double rooms. One double room has an ensuite facility. There is a passenger lift in the old wing and a chair lift in the new wing: however the home is not suitable for independent wheelchair users and does not enable people that require aids and equipment to move around the home independently. The front entrance has one step into the porch and another step into the foyer, level access is through the side entrance. The home has a large garden to the rear with extensive views over the city. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced in order that the provider and manager could be present. The inspection visit took place over two days. Evidence was obtained by a tour of the entire premises, examination of certain records and other documents, discussion with the manager and the provider. Time was spent observing staff interaction with residents, talking with residents about their experience of life within the home and talking with a number of staff about their experience of working in the home. Relatives who visited during the inspection were also consulted. Account was also taken of information gathered during a recent visit to the home in relation to an investigation following a complaint by the provider about the previous inspection and report. This inspection visit concluded with a structured feedback session for the provider and the manager. What the service does well: Residents value the quality of care they receive. Their comments included: “this is the fourth nursing home I have been to and it is the best of the lot”; “the staff are all very kind”; “I get my meals when it suits me, they are very flexible”; “I couldn’t be looked after better”; “I am treated well”; “the food is very good, very rare it isn’t”; “I would rate it 10 out of 10 and can’t think of anything I would want done differently”; “I was in hospital until a few days ago and was glad to get back home, I feel better now”; “the staff are good, my keyworker is like a friend; the food is very good”. A resident on short-term respite said “I couldn’t recommend it highly enough, the staff have been so patient and helpful”. Residents can be assured that their privacy and dignity will be well promoted and that they will be treated with respect. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 6 There is an impressive depth of knowledge amongst the staff team of residents’ individual needs and wishes. Staff work very hard to provide an environment which meets the interests and needs of a diverse group of residents. Residents receive a varied diet which recognises individual preferences and needs. There is a clear culture of active, appropriate advocacy amongst the staff team in order to protect residents from abuse. Staff are undertaking good training which is essentially relevant to them and which is adding to their confidence and competence. They are appropriately supervised. Residents and staff benefit from the manager’s open and inclusive management style. The best interests of residents are promoted by the dedication of the manager and the staff. What has improved since the last inspection? Although it has been only 3 months since the previous inspection, the home has made tangible improvements in a number of areas set out below. A significant programme of improvements to the environment has started. Once completed, this will considerably enhance the home’s facilities and improve its accessibility. There has been a comprehensive review of the Residents Handbook in order to make it legally compliant and to be a fuller source of information for residents and relatives. A fundamental review of care planning documentation has begun to enable it to better reflect the depth of knowledge there is about residents’ needs, wishes and interests. The meals provided are now very well documented. Information about how to make a complaint in the home has been reviewed and awareness of this information is being reinforced: these actions will strengthen confidence that if there are any complaints, they will be listened to, taken seriously and acted upon. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 7 Monthly unannounced visits by a representative of the provider have been resumed and reports of these visits are being supplied to CSCI and to the manager as is required. 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. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 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 the following standard(s): 1, 5 The overall quality in this outcome area is adequate. Once reissued, the Residents Handbook will provide prospective residents with fuller and up-to-date information in order that they can make an informed decision about where to live. Prospective residents and their relatives have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: Since the last inspection, the content of the Residents Handbook has been comprehensively revised in order to comply with legislation. As legislation relating to the contents of the Service User Guide is about to change, it was agreed that the provider will review this document to see if it is affected by the Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 10 amended legislation before finalising it in an accessible format and circulating it to residents, relatives and relevant others. The most recent inspection report will be made readily available in an accessible format to supplement this information. In discussion with residents admitted to the home in recent months, they all confirmed that they or their relatives had opportunity to visit and assess the quality, facilities and suitability of the home. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 11 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, 10 The overall quality in this outcome area is adequate. The documentation of care does not reflect the depth of knowledge amongst the staff team of individual needs and wishes. Residents can be assured that their privacy and dignity will be well promoted and that they will be treated with respect. EVIDENCE: Work has very recently begun on a comprehensive review of how care planning is documented. This has included a meeting with all the staff to discuss the goals of care planning and has led to a draft care plan format which the inspector received a copy of during this inspection. It is understood that this format will be further revised to take into account suggestions made by the manager and inspector. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 12 The inspector was also informed that, as part of this process, responsibility for compiling and reviewing care plans will begin to be delegated to nursing staff, with the manager retaining oversight. The manager confirmed this intention. This review was prompted by the provider acknowledging shortcomings in care plan documentation and in evidence of resident or relative involvement in ongoing review which were identified as part of an investigation into a complaint by the provider about the previous inspection report. Although these shortcomings remain at present, particularly in relation to the documentation of social care needs and promotion of remaining abilities to maintain independence, residents spoken with were very clear about how well their needs and wishes were known and where possible met by staff so that their quality of life was maximised. These views were supported by relatives spoken with. Discussion with the manager and with those care staff interviewed confirmed they acquire a very good knowledge of each person and apply this knowledge to meet identified needs within available resources. Once the new care planning format is finalised and introduced, care plans will need to consistently show evidence of resident or representative involvement in how they are completed and reviewed. On the evidence of those care records sampled, risk assessments in relation to individual residents were in place and relevant. Following the last inspection, it was recommended that life profiles be compiled in relation to each resident who did not already have this, with as much involvement from the resident as possible. This process has been completed for all but 5 residents and contributions from family members have been requested for those remaining. All residents spoken with felt that their privacy and dignity was promoted and felt that were always treated with respect. These views were endorsed by relatives spoken with. At the last inspection, a recommendation was made for there to be a policy for dealing with an unexpected death. The inspector was informed that this will be introduced as part of the overall review of policies and procedures. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 13 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, 15 The overall quality in this outcome area is good. Staff work very hard to provide an environment which meets the social, cultural, religious and recreational interests and needs of a diverse group of residents. Residents are supported to maintain as much contact with friends and family as possible and are helped to exercise as much choice and control over their lives as possible. Residents receive a varied diet which recognises individual preferences and needs. The meals provided are now very well documented. EVIDENCE: Residents at Westcroft include a number of people who are physically but not mentally frail or incapacitated and another group whose mental frailty or incapacity affects them more than their physical condition. This presents challenges in terms of identifying and providing individual and collective Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 14 activities and events which are stimulating: however, this challenge is addressed by the manager and staff team with energy. There is a programme of in-house and external activities; on one of the days of this inspection a musical entertainer visited for the afternoon – this is a regular booking. The lounge and hallway were strongly influenced by the football World Cup in progress, with visual displays as well as a raffle in the hallway. There were also photographs on display from a recent trip to Lacock which had been well received. Residents spoken with were aware of various events and activities that had happened or were planned to happen and confirmed their enjoyment of what was offered and their ability to choose whether to take part or not. Residents meetings are held approximately quarterly and notes from the most recent meeting were prominently displayed on the noticeboard in the hall. The agenda included events within the home, ideas for other trips out, the forthcoming fayre in the garden, and this inspection. During the two days of inspection, a radio playing music of varying styles was on at certain times of the day in the lounge area. The resident who sat next to the radio confirmed that this was their choice and that they like the music. Other residents who used the lounge area who were able to converse said that they were happy with or did not mind the music when it was on. Residents spoken with confirmed they could receive visitors freely. As there are no alternative communal areas, visits in private have to take place in bedrooms but residents spoken with did not express this as inconvenient. Since the last inspection the cook, together with a senior carer who cooks one day per week, have attended the Safer Food Better Business Course and have met with the course assessor in order to begin to implement the ideas that course produced. This initiative is commended. The inspector was informed by the cook that, since the last inspection, there has been good reliability of supply. The weekly ordering pattern has changed and there were no reported problems with this change. Since the last inspection, a detailed record of the food provided each day to each person has been introduced. This record not only reflects the menu or alternative choices made but also shows the time food is to be given to an individual in line with their expressed preference and health need. The resident concerned confirmed this preference is consistently adhered to. The quality of this record is also commended. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 15 All residents spoken with said that they enjoyed the food provided. A relative who has visited weekly for 3 years said that the food his relative receives has always been satisfactory. A number of residents have pureed meals: these were separated on the plate for presentation during the inspection. The cook confirmed that this good practice occurs as often as possible. It would be beneficial for the home to obtain the advice of a qualified nutritionist in terms of portion assessment as well as any other aspects of relevance. Clear records of fridge and freezer temperatures are kept. Although cooked meat temperatures are also being kept, the home has been advised by the Environmental Health Officer that this is not necessary now. In response to recommendations made by the Environmental Health Officer following a visit in March 2006, a new cleaning schedule for the kitchen has been devised and it is understood that redecoration of the kitchen is planned and that its floor covering will be replaced. During the inspection, the need for ventilation in the kitchen to reduce its temperature was apparent. This was raised with the provider who undertook to get a circulation fan. Subsequent to the inspection, the inspector received confirmation that this was now in place and having a beneficial effect. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 16 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 The overall quality in this outcome area is adequate. Information about how to make a complaint in the home has been reviewed and awareness of this information is being reinforced: these actions will strengthen confidence that if there are any complaints, they will be listened to, taken seriously and acted upon. There is a clear culture of active, appropriate advocacy amongst the staff team in order to protect residents from abuse. This culture will be strengthened once the home’s policy review work is concluded. EVIDENCE: Since the last inspection, the complaints procedure has been updated. It is understood this information will serve as a supplement to the Residents Handbook once revisions to that document have been finalised. Information about how to make a complaint was included in the recent residents’ meeting. This sort of reinforcement may need to be supported by accessible formats of the document for some residents. The inspector was informed by the provider that they are looking at further ways of promoting awareness of this procedure amongst relatives. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 17 All residents spoken with during this inspection voiced no complaints. Those asked what they would do if they were dissatisfied were clear who they would go to, as were the two relatives asked. CSCI has received no complaints since the last inspection. The Regulation 26 visit report for May 2006 referred to a complaint by a relative about personal care and stated that this complaint had been resolved. The home’s policy on abuse is awaiting updating so that it does not conflict with the local Inter-Agency Procedure for Protection of Vulnerable Adults. Two staff recruited since the last inspection with the intention of taking part in the home’s adaptation programme have already undertaken both Alerters and Investigators level adult protection training courses provided by the local authority. Whilst the intentions behind their attendance were understandable, the Investigators level course is for managers and senior staff who may need to make referrals and is therefore not appropriate for all care staff. This was shared in feedback with the manager and provider. All staff spoken with had a clear perception of what abuse of a vulnerable adult could mean and all were clear about their role in preventing abuse where they could and in stopping and reporting abuse where they found it. One staff member said she had found the Protection of Vulnerable adults alerters level training day she had attended recently “really good because it made me think about the things that can be done thinking they are for the best when actually they may be abusive”. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 18 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, 23, 24, 26 The overall quality in this outcome area is adequate. The environment is homely, clean and comfortable. Work underway and planned will significantly enhance the home’s facilities and improve accessibility. Residents’ bedrooms suit their needs and are personalised with their own possessions. EVIDENCE: Since the last inspection, a significant amount of improvement work to the property has been committed to by the provider. Some of this work was underway during this inspection. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 19 The most significant improvement is to the first floor bathroom of the old wing which is being converted from a separate bathroom and WC, neither of which were accessible, into a single accessible room. As part of this work, a new bathroom suite is being fitted, a new pole hoist will be fitted for the bath, and the room will be completely redecorated. Once completed, this will mean occupants of the old wing do not have to be transported to the new wing for an assisted bath. The bathroom on the top floor of the old wing is also to be refurbished. Residents were consulted about and chose the design and décor for this room at the most recent residents meeting – this involvement is commended. Some rooms in the old wing would benefit from redecoration, particularly in terms of woodwork on skirtings or in some cases windows. The inspector was informed that redecoration of the exterior of the property is planned for later this year and that two basins in bedrooms are to be replaced shortly. The gardens at the rear of the property are very attractive and much appreciated by residents and relatives spoken with. Accessibility to this garden would be made easier by the addition of a small ramp to cover the drop between the end of the flagstone path and the start of the grass area. Shared space consists of a lounge/dining room area. Both areas are used as necessary at mealtimes. The sitting area can accommodate 10 people to sit and socialize. As the home offers accommodation for twenty-one individuals, the space is limited for the whole resident group to sit together and share activities: however, as a number of residents are bedbound, this is currently less of a problem than it could be. All residents bedrooms were seen. Each room was personalised; the degree of personalisation varied according to individual circumstances, wishes and the amount of nursing equipment needed. Each person spoken with was happy with their room. Since the last inspection, finishing off work identified at that inspection relating to minor repairs in bedrooms has been carried out. During the inspection, a bedroom with torn flooring had its flooring replaced. A shared bedroom which lacked a second wardrobe at the last inspection now has a second wardrobe. One bedroom has had a new carpet. Since the last inspection, 7 commode chairs have been replaced. The inspector was informed by the manager that all of the remainder will also be replaced in the near future. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 20 Since the last inspection, an order has been placed for lockable furniture for those bedrooms which currently do not have this facility. A number of bedrooms are not lockable due to their construction. The Statement of Purpose, once finalised, must therefore include this information in its description of the facilities and restrictions of the building available at the home. There was a good overall standard of cleanliness. Following discussion with the cleaner, the provider, the manager, and noting comments from a relative, it is recommended that additional support for periodic deep cleaning of the whole property be reintroduced as this cannot be achieved by the cleaner alone on the hours available. A replacement vacuum cleaner was needed during the inspection and was being obtained by the provider as the inspection was finishing. Since the last inspection, the system for sorting and returning residents’ laundry after it has been washed has been revised. The manager and the staff member responsible both felt this was a good system and residents asked said their laundry was managed well. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 21 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 The overall quality in this outcome area is adequate. Residents are in safe hands. Their physical needs are met by the staff team but current staffing levels may inhibit the level to which emotional needs can be addressed and should be restored to how they were before the previous inspection. Staff are undertaking good training which is essentially relevant to them and which is adding to their confidence and competence but there are some gaps in mandatory training to be addressed. The home’s recruitment processes and adaptation programme will be a focus of the next inspection. EVIDENCE: The home has a number of staff who have worked at the home for many years. This provides tremendous continuity for the residents, some of whom have also lived at the home for a number of years. These longstanding staff are complemented by staff who have trained as nurses in their country of origin and who are either waiting to start their Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 22 adaptation programme to become a registered Nurse in the United Kingdom or who are on their adaptation programme. These staff are employed as care assistants. One of these staff is carrying out laundry and care duties. The nature of adaptation courses means that there is typically a change of personnel every 8 or 9 months. The manager does not recruit these students but is responsible for monitoring their progress. The students are mentored by the provider who determines at the end of their programme if they are competent practitioners. Available staffing rotas showed that the home’s Staffing Notice is being complied with. However, this Notice sets minimum staffing levels for Registered Nurses and care staff according to the numbers of residents on a banding system. To comply with the Regulations, staffing levels must be sufficient by taking into account the circumstances of the home at all times. Usually, this equates to the level of dependency amongst residents in terms of staff support for their physical, social or mental care needs. There are a number of residents at Westcroft with considerable levels of dependency due to physical conditions, mental conditions, or sometimes both. However, another relevant factor at Westcroft is the role that the Registered Manager and other Nurses have on a daily basis in overseeing the work of the adaptation students – this can place pressure on other areas of work to be done. There were examples witnessed during this inspection and noted on other documents of work done by some of the staff well beyond their paid hours – for example, assisting and encouraging residents who attended the musical entertainment to participate. Staff confirmed when interviewed that their keyworker role did not have ringfenced time for 1:1 work. One person said opportunities had to be negotiated and sometimes could not be taken up because of the level of work associated with people’s physical needs. Some of the residents spoken with commented on how busy the staff were and how they made time for them as best they could. Until recently, there was an additional care assistant rostered on the 8am-2pm and 2pm-8pm shifts. It is unclear why this reduction has been made as the level of physical dependency amongst residents has not reduced to a corresponding degree. When considered together with the issues identified in the management section of this report, the evidence of this inspection suggests that current levels do not adequately enable all needs to be met and that a restoration of staffing levels to their previous state should be implemented by the provider. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 23 Available Induction records showed that Induction had been completed for all staff but that there was incomplete sign off by either the inductee or the mentor. Available records of training showed that a wide variety of training has taken place during 2006 and that this level of activity is planned to continue. Courses that individuals or groups have attended include:Falls awareness, recognising cultural differences, equality and diversity, depression in the elderly, wound care, communication, mental health awareness, stroke & epilepsy, venepuncture, and continence. Courses staff plan to attend later this year include mental health in later life, care of medicines, and communicating with people in distress. All but one of the regular staff (there are a few ‘bank’ staff who may work very occasionally) have attended or will attend training in dementia care over a 12 month period. This is impressive but also necessary given the proportion of residents in the home with diagnosed or probable dementia. Staff undertake a lot of training in their own time, which reflects the high level of motivation most hold towards their professional development. The records were inconclusive as to whether staff receive the minimum of 3 days paid training per year (including in-house training) that National Minimum Standard 30.4 expects. Notwithstanding this range of training, there are some gaps in mandatory training aspects which need to be addressed. These consist principally of some staff needing to receive training in first aid, health and safety and protection of vulnerable adults (alerters level or equivalent). The inspector recommended that the manager compile a training matrix as this would provide a full but concise overview of what training had been done and what the gaps were and would therefore help forward planning. Two care staff have their NVQ Level 2 and one is planning to do their NVQ 3. The cook is also planning to do an NVQ award. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 24 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, 32, 33, 35, 36, 37, 38 The overall quality in this outcome area is good. The manager is fit to be in charge but needs additional resources from the provider in order to discharge her responsibilities fully. Residents and staff benefit from the manager’s open and inclusive management style. The best interests of residents are promoted by the dedication of the manager and the staff and these interests will be further safeguarded by the reviews of the home’s quality assurance processes, record keeping, policies and procedures which the provider is instigating. Residents’ financial interests are safeguarded. Staff are appropriately supervised. The health, safety and welfare of staff and service users is promoted and protected. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager Mrs Ramjutton now has 11 hours supernumerary time per week to achieve the requirements of her role. This includes the supervision of staff, managing day-to-day events and overseeing the delivery and planning of clinical and non-clinical care. It also includes responsibility for monitoring the day to day performance and progress of staff who are students on adaptation programmes and following a recent audit of the programme in place at Westcroft, there is every possibility that the number of such students at Westcroft at any one time will rise from two to three which will increase this aspect of her workload further. This amount of supernumerary time has been reduced since the last inspection from 15 hours. There is no Deputy manager and no allotted administrative support. In discussion, the manager expressed her intention to delegate certain tasks to her nursing staff, principally that of the documentation of care plans: however, this will first require training and oversight from the manager to ensure the delegated task is fully understood. Since the last inspection, Mrs Ramjutton’s registration as manager by CSCI has been confirmed. She continues to undertake the Registered Manager’s Award and has appropriately maintained her professional development via clinical and non-clinical courses. All residents and staff spoken with had nothing but praise for Mrs Ramjutton. One staff member said “she is fantastic, very supportive, puts herself in my shoes”. All staff spoken with felt that there had been improvements in the home since the last inspection. All staff spoken with confirmed that they are supervised in a structured way on a one to one basis in addition to day-to-day supervision and support. They all said they felt the formal and informal supervision they receive to be beneficial. Just prior to the last inspection, the manager and two other senior staff (one day and one night staff) attended a supervision skills course. In view of the manager’s workload issues identified above, it is recommended that ways of appropriately delegating supervision responsibilites to these two staff without Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 26 adversely affecting their existing duties be actively explored by the provider in conjunction with all involved. At the start of the inspection, the provider confirmed her intention to carry out a systematic review of the home’s quality assurance self-assessment document. This document had first been produced in July 2003 and was drawn up in relation to previous legislation. It needs to be measured by current legislation and by the National Minimum Standards. The inspector advised the provider of the imminent changes in the regulation that relates to quality review and suggested that this review be held after this legislative change has happened. Since the last inspection, the actions taken by the provider as a result of the outcome of the quality questionnaire carried out just prior to that inspection have been displayed on the noticeboard in the entrance to the home. This is commended but the recommendation to produce an annual development plan following the quality assurance surveys is reiterated as this will consolidate the transparency of how continuous improvement in the home’s quality of service will be sought. Also since the last inspection, monthly unannounced visits by a representative of the provider have recommenced. Reports of these visits are being copied to CSCI and by the manager. The requirement made at the last inspection has therefore been complied with. It is, however, suggested that the person carrying out these visits take account of the sample version of these reports which is available via the CSCI website as this may help provide a fuller report. No residents currently control their own finances. The records of residents’ monies were checked. The monies are kept in separate containers with individual books. A sample audit showed correct balances and accurate entries in records. There were two staff signatures for all transactions. Balance audits are now occurring monthly. At the start of the inspection, the provider confirmed her intention to carry out a systematic review of the home’s policies and procedures with the involvement of the manager and others as relevant. Reference to specific records is made in the relevant sections of this report. Following the last inspection, a requirement was made for the workplace risk assessment to be reviewed. This review has started and ways to proceed effectively were discussed by the inspector and the manager during this inspection. Since the last inspection, the home’s fire safety risk assessment has been revised to take account of a resident’s smoking preferences. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 27 At the last inspection, there was a trailing call bell lead in a bedroom and the need to assess the risk of this was identified: since then, this risk has been removed by the repositioning of the bed, with the agreement of the resident. Regulation 37 reports are being sent to the CSCI in accordance with this regulation for any incidents/accidents which could adversely affect the residents. The inspector discussed a couple of examples in the accident record with the manager which could be viewed as notifiable in that they indicate a pattern and recommended that the manager consult CSCI if unsure if an event is notifiable. Fire safety and other equipment is being tested in accordance with stipulated frequencies. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 28 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 2 X X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 3 Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 4&5 Schedule 1 Requirement a) Ensure the Service User Guide includes the information recorded in Standard 1 of the report and is given to each service user. b) Ensure the Statement of Purpose reflects the facilities available and the restrictions of the environment and complies with all other aspects of Schedule 1. This is a repeated requirement – timescale extended. Ensure care plans consistently show evidence of resident or representative involvement in how they are completed and reviewed. This is a repeated requirement – timescale extended. Ensure all staff receive mandatory training in first aid, health and safety and protection of vulnerable adults (alerters level or equivalent). Timescale for action 30/09/06 2. OP7 15(1), 15(2) 31/10/06 3. OP30 18(1)(a) 30/11/06 Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 30 4. OP31 10(1), 12(1)(a) Provide the registered manager 31/08/06 with administrative support and restore her supernumerary hours to 15 per week to enable her to carry out the full range of her duties. Complete the update of the Workplace Risk Assessment. This is a repeated requirement – timescale extended. 31/10/06 5. OP38 13(4)(c) 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 OP15 Good Practice Recommendations Obtain the advice of a qualified nutritionist in terms of portion assessment as well as any other aspects of relevance. Improve accessibility to the rear garden by the addition of a small ramp to cover the drop between the end of the flagstone path and the start of the grass area. Reintroduce additional support for periodic deep cleaning of the whole property. Restore staffing levels to how they were before the previous inspection. The manager compile a training matrix to provide a full but concise overview of what training has been done and what the gaps are to help forward planning. The provider review whether staff receive the minimum of 3 days paid training per year (including in-house training) and if not then ensure they do. 2. OP24 3. 4. 5. OP26 OP27 OP30 6. OP30 Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 31 7. 8. 9. 10. OP33 OP36 OP37 OP37 Produce an annual development plan following the quality assurance surveys. Explore ways of appropriately delegating supervision responsibilities. The manager consult CSCI if unsure if an event is notifiable. Ensure Induction records are signed off by the inductee and the mentor. Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Westcroft DS0000020315.V302328.R01.S.doc Version 5.2 Page 33 - 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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