Inspection on 13/09/05 for Westdene Residential Home

This inspection was carried out on 13th September 2005.

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

Westdene Residential Home 25/10/07

Westdene Residential Home 02/11/06

Westdene Residential Home 24/01/06

Westdene Residential Home 22/07/04

Westdene Residential Home 03/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Westdene Residential Home 15-19 Alliance Avenue Albert Avenue Kingston upon Hull HU3 6QU Lead Inspector John Gregory Unannounced 13 September 2005 @ 8:00 am 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. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westdene Residential Home Address 15-19 Alliance Avenue Albert Avenue Kingston upon Hull HU3 6QU 01482 506313 01482 573985 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) Mrs Margaret Every Mrs Margaret Every Care Home 30 Category(ies) of OP Old Age (30) registration, with number DE(E) Dementia - over 65 (30) of places Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home may provide personal care to one service user, named on the CSCI file, who is under pensionable age Date of last inspection 1st February 2005 Brief Description of the Service: Westdene is a care home providing accomodation and personal care to 30 persons experiencing issues related to the aging process.The enterprise is privately owned and the owner is also the registered manager. The accomodation consists of three extended and adapted victorian houses ajacent to Anlaby Rd close to the centre of Hull. The accomodation is over two floors that are joined by a shaft lift.There are twenty-six single rooms and two double homes.The home has a range of communal facilities.There is a garden to the rear of the premises and a car park to the side of the home. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one morning in September 2005.Only those standards were inspected that the CSCI consider as central to the caring process and those where their had been a requirement made at the last inspection. A sample of policies procedures and records were examined that were relevant to the standards inspected. A brief inspection of the premises was undertaken. Five case files were examined two of which were examined in further detail. Five staffing files were examined. Interviews were held in private with four staff and four service users, one of which was receiving respite care. The deputy manager assisted the inspector throughout the inspection. The inspector would like to thank the owner managers’ staff and service users of Westdene for their time cooperation and hospitality during this inspection. What the service does well: What has improved since the last inspection? The service provider has fitted a new kitchen and continued with a programme of maintaining the home. The few requirements made at the last inspection have been addressed. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 6 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. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1&3 The home operates on the basis of good information for service users and their carers. Service users are admitted on the basis of a comprehensive assessment to ensure that their needs can be met. EVIDENCE: The statement of purpose and the service users guide have been updated to meet the necessary standards. These documents now provide good information for service users and their carers. All the files examined contained evidence of either the homes own assessment or one undertaken under the care management arrangements. One case had been admitted as an emergency and the staff had completed an assessment of needs as soon as the person was admitted. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 & 10 Service users receive structured care, good medical care, which is supported by a medication system that protects service users. Transactions and life within the home ensures that service users are treated with respect and their privacy is respected. EVIDENCE: The care plans examined covered a wide area of the service users needs and was reviewed monthly by staff within the home. A broader review of the service users needs is undertaken under the care management arrangements. The files confirmed the view of service users that they received good medical care based on the primary health care team and where necessary referral for hospital based care. It was noted on one service users file that issues of nutrition were involved in the necessity for admission and although service users were weighed there was no systematic form of nutritional assessment for service users. The medication system was examined and audited and found to be satisfactory. Transactions between staff and service users were seen to be positive professional and good-natured. Service users can make full use of their rooms and those service users using double rooms have privacy screening available. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 10 Service users confirmed that they had access to a phone and one service user was seen to have their own phone installed in their own room. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13&15 Service users have access to recreational and social activities and have regular and frequent contact with their family and visitors. The meals were in the main appreciated by service users. EVIDENCE: The home employs a care assistant who also acts as an activities coordinator. A list of the weekly activities was posted on a board at the entrance. Service users acknowledged the difficulty in undertaking activities that were suitable for the wide range of disabilities experienced by fellow service users. Some service users found the range of activities did not meet their particular needs; but recognised that they had alternative social events and activities arranged through family and social contacts. All the service users confirmed the good visiting arrangements and visitors were seen in the home at various times through the inspection. The menu was seen and offered food over a four weekly cycle. The menu was seen to offer a wide range of food. The meal is served in the main dining area and service users confirmed that they had choice available should they not like the food offered on the day. Service users were in the main happy with the food and choices available for them. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16&18 Service users are confident that their complaints will be listened to and staff are familiar with the procedure to which some minor attention is needed. The service provider has a robust policy and procedure for the prevention of abuse, which is understood by staff and protects service users. EVIDENCE: The service provider has a complaints procedure, which needs to be modified to include relevant time scales. The staff understood how to operate the procedure and service users were confident that their complaints would be listened to and dealt with effectively. The service provider has a procedure for the prevention of abuse and whistle blowing. Both procedures are understood by staff who have had some basic training in the matter. Staff were confident in their ability to deal with any challenging behaviour exhibited by service users. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19&26 The service users live in a clean, safe, well maintained and well decorated home. EVIDENCE: The home was seen to be clean tidy, well decorated and furnished in a domestic style. The service users rooms were light airy and personalised with service users effects. The laundry was seen and contained commercial washing equipment and had impervious floors and ceiling. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,29 & 30 The home is basically well staffed by well-trained staff. The recruitment process is robust and supports and protects service users. EVIDENCE: The rota was examined and confirmed that staffing is based on five staff on duty in a morning, three staff in an afternoon and two waking night staff. The manager is supernumery to the rota. A good level of domestic laundry and catering staff supports care staff. The recruitment process was examined and found to be robust with all the required information being obtained on new appointments to the home and on existing staff. Staff were able to confirm the information on record that they had received a wide range of training concerning issues related to health and safety and on issues related to the direct an specialist care of service users. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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) 33&38 The home is run in the best interests of service users through a quality assurance system. The systems and practice in the home protect the health welfare and safety of service users and only minor attention to detail is necessary. EVIDENCE: The service provider has quality assurance system which involves the routine setting of targets, the regular auditing of those targets with action plans being set for any shortfalls, Service users are consulted on the service they receive and the results are made available in the home. The service provider undertakes routine Fire and workplace risk assessments in the home. The fire alarm and emergency lighting systems are regularly tested. There is a monthly-simulated fire drill with the staff although it is not recorded as a drill. COSHH records and procedures are in order. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 16 Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 17 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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 3 x x x x 2 Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 18 No 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 Regulation Requirement Timescale for action 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. 3. Refer to Standard OP 8 OP 18 OP 38 Good Practice Recommendations All service users should be subject to nutritional assessment The service provider should include the timescales for responses in the complaints procedure. The service provider should separately record fire drills. Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Westdene Residential Home J54_s875_Westdene_v242183_130905_Stage 4.doc Version 1.40 Page 20 - 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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