Inspection on 09/05/07 for Westdale Care Home

This inspection was carried out on 9th May 2007.

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

Westdale Care Home 16/09/05

Westdale Care Home 29/12/04

Westdale Care Home 14/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westdale Care Home 129 Melton Road West Bridgford Nottingham NG2 6FG Lead Inspector Michael Williams Unannounced Inspection 9th May 2007 09:00 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 Westdale Care Home DS0000008805.V323816.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. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westdale Care Home Address 129 Melton Road West Bridgford Nottingham NG2 6FG 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) 0115 233128 0115 233128 westdale1@btconnect.com Westdale Quaker Housing Association Limited Mrs Linda Margaret Orchard Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. I bed is to be used for short term respite care only Date of last inspection 16th September 2005 Brief Description of the Service: Westdale is registered to provide personal care and accommodation for up to 19 older people. It does not provide nursing. The home is owned by a voluntary organisation and it is located on a main road in West Bradford. There are shops, churches, restaurants, public houses and public transport links in the centre of West Bradford. The home is an adapted period property with an extension over two floors. There is a vertical lift and stair lift to provide access to the upper floor. All bedrooms are single and 10 have en suite facilities, one bedroom is below minimum space requirements and is only used for respite care. There is a large, and attractive and well-maintained gardens to the rear of the property with seating available. There is a small care park to the front. The fees are £1530 per calendar month, newspapers, hairdressing, chiropody are not included. This and other information about the service is included in the Statement of Purpose and service user guide, which the manager makes available to prospective service users on express of interest in accommodation. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspection visit undertaken by the Commission for Social Care Inspection is upon outcomes for service users, and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that require further development. This was an unannounced undertaken by two inspectors over 6 hours. The main method of inspection used was called ‘case tracking’ which involved selecting two Service users and tracking the care they receive through checking their records and discussion with them, and observations of the care received and asking staff about their needs. Records of complaints, staff training, quality assurance, and Health and Safety records were also looked at. Two members of staff and one relative were spoken with as part of the inspection. The views of Service users who were not part of the ‘case tracking were sought to form an opinion about the quality of care provided. A partial tour of the premises was undertaken and the bedrooms of the case tracked Service users seen to ensure that the environment was homely and safe. A pre inspection Questionnaire was completed by the manager before the inspection, this together with a review of all the information about the home received by the Commission since the last inspection was taken into consideration in planning this inspection and helped in deciding what areas of care were looked at. What the service does well: Service users are well cared for and said that they feel happy and settled living at home. Access to activities is made available for service users, both in the home and in the community and they are enabled to make choices about whether to be involved or not. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 6 Service users are supported to lead the life they choose, the routines in the home are flexible and service users are offered a choice of lifestyle. Staff also encourage and support service users in maintaining existing and developing new friendships. Nutritious and varied food is provided, Service users say that the food is “very good,” and they get choices and plenty to eat. The home is comfortable, homely, and clean and has a pleasant atmosphere for service users to live in. People living here say that they are happy living at the home and like their rooms. Service users are protected by a robust staff recruitment policy and procedures and a commitment to the development and training of staff. The views of service users are sought, and regularly consulted about their views and opinions and feel confident in voicing any concerns at any time. What has improved since the last inspection? What they could do better: Care plans require further development around the specifics of how individual care is delivered by staff and assessments around individual needs such as sexuality also need to be taken into consideration. Dates and signatures of when care plans are developed also need to be included in care plans. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 7 Medication policy and procedures need to be revised to safeguard service users from harm. A review of the adult protection policy is recommended to ensure that staff complies with Nottinghamshire Adult Protection procedures, and that appropriate action is taken to reduce risk. 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. The summary of this inspection report can be made available in other formats on request. Westdale Care Home DS0000008805.V323816.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 Westdale Care Home DS0000008805.V323816.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good Individual assessment of needs is undertaken and service users are provided with relevant information to make informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full assessment of need is undertaken before service users are admitted to the home; this information is then used to inform the development of care plans. Wide areas of need are considered during assessment including Self-medication. Information about family history is also available to enable staff to Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 10 Develop a person centred approach to the care provided to service users but no assessment is undertaken with regard to service users sexuality. Some of the files examined contained contracts and combined service user guides. However one file did not contain this information. Westdale Care Home DS0000008805.V323816.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. Care plans are not fully reflective of holistic individual needs. Service users may be place at risk by the home’s medication administration policy and procedures This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans have recently been revised by the home’s management, with the emphasis upon ensuring that the care plans are a “Living Document” which is designed to inform staff of service users individual needs. The assessment of need is generally well completed, but the care plans lack the specifics of the support that the service user requires. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 12 Information was also missing from the some care plans examined, for example, the level of help needed for personal hygiene, incontinence, and medication for constipation. The Care plans examined did not have the date of signature to indicate when completed. The administration of medication was observed and the staff member observed placed tablets into her own hand before passing them to a service user, which is poor practice. Medication administration records (MAR) were also being signed before medication was administered to Service users, which is also poor practice. Service users spoken with said that they were happy with the way care is offered, staff knocked on doors before entering and were discreet and respectful in the way they offered help. Service users feel their privacy is maintained and said that the “staff help you but also encourage independence” Westdale Care Home DS0000008805.V323816.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Service users are offered choice and control to lead their lives in the way that they wish and are encouraged and supported to maintain family and social relationships This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are consulted about interests, and regular activities are provided for service users such as baking, craftwork and exercise classes. One person living at the home said she enjoyed spending time reading and doing craftwork. Another person reported that outings are provided and confirmed there are regular trips out to garden centres, parks and local shops. Religious services are available at the home on a weekly basis according to the beliefs of those accommodated. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 14 This was further evidenced in the examination of resident’s meetings minutes and during dicussions undertaken with members of staff. The menus appeared appetising and nutritious. Lunch was observed and the meal for the day was roast pork, roast potatoes, Yorkshire puddings, assorted vegetables followed by a choice of sweet. Service users spoken with said that they liked the food “especially the puddings”. Service users are encouraged to bring their own furniture on admission subject to health and safety compliance regulations. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. Resident’s complaints are acted upon Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure available to service users and their families, it includes appropriate timescales for responding. There are no recorded complaints, however, any concerns raised are logged within the general handover book. Service users and relatives spoken with said that they felt confident in voicing any concerns to the manager . Training records indicated that staff have attended adult protection training and staff spoken with were aware of adult safeguarding procedures. There is a safeguarding Adults policy available at the home together with a copy of the Nottinghamshire Abuse procedures which indicates processes for Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 16 dealing with complaints. However the policy does does not specifically stipulate the need to contact social services in any such instances as required. Examination of individual service user records highlighted a significant incident, which was dealt with internally which is not compliant with Nottinghamshire Adult Protection procedures indicating that staff are not fully conversant with the practical application. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25,26 Quality in this outcome area is adequate. The majority of the environment is safe and well maintained, but a number of unattended issues pose a risk to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained internally and externally. A partial tour of the building found the home to be generally well furnished, clean and inviting. Some carpeted areas are worn and being taped over to prevent trip hazard. Records were seen to evidence that processes were underway to obtain quotes for replacement carpets. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 18 There are two lounge areas, the main lounge at the front of the home is not large enough to accommodate all Service users simultaneously, however there is a smaller lounge at the rear of the property which is also available, and staff reported this to be well used and a good alternative if one or more service users wished to engage in activities other than watching the TV. There is sufficient individual and communal space available to allow service users to entertain visitors in private. The dining room area is light and spacious, with adequate space to comfortably accommodate all service users appropriately at mealtimes. The menu for the next meal is highlighted on a menu board. The room is set up well with placemats, drinks, napkins and cutlery arranged in advance of the upcoming meal. Service users bedrooms viewed were spacious, clean and pleasant. Service users are encouraged to bring their own furniture on admission subject to health and safety compliance regulations. A number of downstairs windows were seen open for ventilation purposes in rooms with little or no staff presence. This could pose a risk of intruders. There are sufficient bathrooms and toilets throughout to accommodate service users with specialist bathing facilities available for those who may require such support. There is a fully operational stair lift and passenger lift, both if which support service users access the first floor. During a partial tour of the building we found the stained glass window at the top of the stairs has not been fixed with a restrainer. Similarly, the sash window in the bathroom at the top of the stairs is not restricted. Both pose a risk to service users. Additional to this the bookcase in the back hallway has a broken pain, which although taped, could pose a risk to service users from rubbing or falling against it. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 30 Quality in this outcome area is good. Staff recruitment policy and practices ensure that service users are protected and staffs is adequately trained to meet service users needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 38 Quality in this outcome area is good. The home is well managed and run in the best interests of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well managed; and the relaxed and pleasant approach is reflected in the pleasant and welcoming atmosphere of the home. Service users, staff and relatives spoken with say that they are happy with the way in which the home is run. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 21 Resident are consulted about the running of the home. Resident meetings are held infrequently, but a good range of topics such as food, activities, outings and the views on practice are invited. Servicing and maintenance checks are being undertaken as required, including water temperatures to prevent Legionella. Fire records indicated that all tests, checks and servicing of fire equipment are being made. The fire risk assessment document viewed, which was completed in October 2006, highlighted areas for action by the provider/manager including the level of seriousness. The majority of issues have been addressed with one high priority exception, namely the fire doors and surrounds that require replacement as the seals are not sufficient. Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 22 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 2 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 X 3 3 X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 7:2 Requirement Care plans must detail specific actions required by care staff to ensure that all aspects of the health personal, and social care needs of the service user are met. Staff must be trained and competent in the administration of medication to ensure service users are protected from harm All suspicion or evidence of abuse must be dealt with in compliance with Nottinghamshire Adult Protection Procedures to ensure the safety and protection of service users. To reduce the potential risks to service users the bookcase in the back hallway with a broken glass pane must be replaced To maintain safety and reduce the risk to service users a risk assessment must be undertaken in relation to the following upstairs windows without restrainers. • stained glass window at the top of the stairs the sash window in the bathroom DS0000008805.V323816.R01.S.doc Timescale for action 20/07/07 2. OP9 13:2 20/07/07 3. OP18 37:1(e) 20/07/07 4. OP19 13:4(a) 20/07/07 5. OP19 13:4(c) 20/07/07 Westdale Care Home Version 5.2 Page 24 6. OP38 23:99(c) To maintain the safety of service users the fire doors and surrounds must be replaced. 20/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP38 OP30 Good Practice Recommendations All service should have a written contract/terms and conditions of the home made available for inspection. A staff traing matrix should be implemented to provide clear overview of which staff have completed training and which staff have not. A record of complaints and concerns should be maintained separate from the handover book to clarity of what actions have been taken by the provider to resolve complaints and maintain confidentiality A risk assessment should be completed in light of previous report of possible intruder in the home. 3. OP16 4. OP19 Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Westdale Care Home DS0000008805.V323816.R01.S.doc Version 5.2 Page 26 - 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!