Inspection on 02/11/06 for Westdene Residential Home

This inspection was carried out on 2nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 24/01/06

Westdene Residential Home 13/09/05

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 Hull East Yorkshire HU3 6QU Lead Inspector Beverley Hill Unannounced Inspection 2nd November 2006 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 Westdene Residential Home DS0000000875.V295622.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. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westdene Residential Home Address 15-19 Alliance Avenue Albert Avenue Hull East Yorkshire HU3 6QU 01482 506313 01482 573985 westdene@westdene.karoo.co.uk 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) Mrs Margaret Every Mrs Heather Burns Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Westdene is a large and extended Victorian House in Hull close to local shops and amenities and on a bus route into the town centre. The home provides care and support to thirty older people with a broad range of needs including dementia. The home has two floors serviced by a through floor lift and stairs, one set of which has a chair lift. The home has twenty-six single bedrooms and two shared rooms. Fifteen of the bedrooms are en-suite. There are two bathrooms upstairs and a bathroom and shower room downstairs. There are ample toilets throughout the home. The home has two lounges and a large dining room set out with individual tables to seat four to six people at each. There is a CCTV in the dining room to alert staff to visitors at the rear of the building. The home also has a pleasant quiet area on the landing with chairs, occasional tables and a television. The home has an enclosed garden, a patio area and a car park to the rear of the building. According to information received from the home on 15.09.06 their weekly fees range between £327.50 and £357.60. The home has a £20 a week top up fee. Items not included in the fee are hairdressing and newspapers if people prefer alternatives to the one provided. The manager confirmed that the proprietor paid for service users to have chiropody care. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit took place over one day. Throughout the day the inspector spoke to six service users to gain a picture of what life was like for people who lived at Westdene. The inspector also had discussions with the registered manager, assistant manager, care staff and catering staff. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them, and checked out with them their understanding of how to maintain privacy, dignity and choice. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, some family members, a selection of staff members and professional visitors to the home. Those returned were checked and comments used throughout the report. Out of nine returned from service users eight stated they ‘always’ or ‘usually’ received the care and support they needed whilst the remaining one stated this was ‘sometimes’ and all nine felt that staff listened to them and acted on this. People were generally aware of how to make a complaint and all surveys felt the home was clean and tidy. Two of the four replies from relatives stated that they felt there was not enough staff and one commented that consultation could be improved, however all were satisfied with the overall care. Two out of nine staff surveys received thought there could be more staff to enable more time to be spent with service users but all felt service users were well looked after. Eight of the staff stated they received support and direction from managers, whilst one person stated this happened most of the time. Two surveys from visiting professionals gave positive comments about the home and staff stating staff members were polite and, ‘really seem to care about the service users’. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home had completed the things the inspector had asked them to complete at the last inspection. The dining room had been redecorated and the corridors had been damp proofed and laid with new flooring. Two bedrooms had also had new flooring and some ceilings had been redecorated. These changes have made the dining room a more pleasant place for service users. The new flooring made a difference to a malodour that was noticed at the last inspection. On this visit the home was clean and fresh. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 7 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 Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 9 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 Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 10 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): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had assessments of need completed prior to admission and in most cases the home obtained copies of assessments completed by care management. This enabled the home to have full information about the service user in order to meet needs. In one case this was deficient and could lead to important information about the service user being missed. The home offered visits and trial stays so people could assess the services provided by the home. EVIDENCE: The inspector examined four care files and three had assessments completed prior to admission, however the home had not obtained an assessment or care plan for a newly admitted service user, funded by another local authority. The assessments and care plans contained important information on which the Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 11 home based their decision about whether they could meet needs and it was important that these were obtained in all cases. There was evidence that the manager completed assessments and the information enabled the home to produce care plans, which set out the service users needs and how they were to be met. After the assessment the manager formally wrote to the service user or their representative stating the homes capacity to meet needs. One care file indicated that the assessment and subsequent care plan addressed issues of diversity with clear nutritional needs established and when checked later these were followed through in practice. The manager and staff confirmed that the home offered short respite stays or visits for a meal and this enabled people to see what the home was like. The first few weeks of admission were seen as a trial period, after which a review was held and the service user and their relatives discussed the option of permanent residency. The home had service users currently using the respite service. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most of the service users health and social care needs were planned for and met in a way that promoted privacy and dignity. Deficiencies in care planning for people with dementia care needs could mean that service users receive inadequate care. The home must be more proactive in assessing and planning for risk situations to ensure service users welfare and safety are promoted. EVIDENCE: The inspector examined four care files and they contained a wealth of information and assessments to enable staff to formulate care plans. The care plans, termed goal plans, indicated the identified needs and the tasks staff had to complete to meet them. The goal plans reflected the need to respect privacy and dignity and promote independence. Generally needs were clear, however in two cases the service users had needs associated with dementia but these had not been addressed fully in the goal plan. One care file had a behaviour management plan completed by a visiting professional, which detailed the Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 13 approaches and monitoring required and this needed to be reflected in the homes goal plan to ensure all staff were aware of its importance. Goal plans were reviewed and there was evidence that the manager audited care files. There was evidence that staff completed monitoring forms for professionals in order to provide them with information they needed to make clinical decisions about care. However staff were unable to monitor the weight of service users unable to stand, as the home did not have any sitting scales. One staff member spoken to stated they tended to monitor this via their appetite and then refer to the GP but a more effective system was required. A generic risk assessment had been completed that covered general issues but some risk assessments needed to be more in depth. For example one service user had bedrails in place but a risk assessment had not been completed as to the reasons why they were needed. Another person had clear mobility needs and the accident records indicated two occasions when their wheelchair had tipped backwards. The risk assessment in place needed to reflect this risk and actions to be taken to minimise serious injury. An immediate requirement was issued for the home to address this concern and a subsequent check found that they had acted promptly notifying the appropriate services, completing a risk assessment and alerting staff to monitor and be vigilant. Staff members spoken to and surveys received from them indicated that they had a good understanding of how to provide care that maintained privacy, dignity, choice and independence. ‘When someone is admitted I visit them to check what diet they have, likes and dislikes’, ‘we ask people what they want to do and we always knock on doors and make sure curtains and doors are closed’, ‘we support and encourage service users to keep their independence’. Service users spoken to confirmed care was provided well. ‘They always knock on doors and help us get ready in the morning’, ‘the staff are absolutely fantastic they come around at night and check me and cover me up’. The inspector observed staff members speaking to service users in a genuinely caring way. Medication was managed appropriately. It was signed on receipt into the home, on administration and when returned to the pharmacy. Medication including controlled drugs was stored and recorded in accordance with legislation, and stock control was managed well. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had flexible routines and promoted choice and individual decisionmaking. The meals provided were varied, well prepared and well presented. EVIDENCE: There was evidence that the home provided some activities for people such as bingo sessions, cards and dominoes, foot spa’s, manicures, clothes parties and special occasion parties, memory games, musical quizzes, crafts and large ball games for exercise. The home also had monthly visiting entertainers. Some service users had recently visited Hull Fair and some attended a harvest festival at a local school. No record was made of any attendance during activities apart from daily records but when these were examined they did not reflect participation. The home needed to ensure that records were maintained of service users who had participated and whether they had enjoyed the activity. This would enable activities to be tailored to service users needs and an ‘at a glance’ record would alert staff when service users were not participating so they can establish if this was due to choice or not providing the right stimulation. Eight of the nine surveys received from service users stated the home provided activities always or usually. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 15 One staff member had supported a service user to complete a life history and the manager showed the inspector a new book the home had purchased which detailed activities for residential and nursing homes and paid special attention to service users with dementia care needs. The home had advertised for an activity coordinator to enhance the provision already in place. Service users spoken to stated their visitors could come at anytime and could be seen in private. They confirmed that there were no set times for rising or retiring and one person spoke about how they liked to get ready for bed but stayed up late to watch TV. One person spoke about being active around the home pottering in their own bedroom but also helping to set tables some days. Staff spoken to were conscious that some service users with memory impairment were not able to make a lot of choices but they stressed they tried to assist this as much as possible. Service users spoken to stated that the meals were very good, although one person said, ‘sometimes it can be a little cold’. Menus offered variety and choice and although there was only one choice at the main meal, service users confirmed they could have something else if they chose. One person said, ‘bacon and egg would be nice for a change’. The meal sampled on the day was well cooked and presented with good portion sizes and fresh vegetables. Staff were observed asking people if they wanted more and bringing second helpings to those who did. There were plenty of staff around to assist people and the atmosphere was relaxed. The home was able to cater for special health diets, for example, diabetics and individual cultural preferences for others. Some people had their meals liquidised and these were done appropriately with each food group liquidised separately. The cook visited new service users when they arrived to check on dietary requirements and it was suggested that they received assessment information from care staff to compliment this. Westdene Residential Home DS0000000875.V295622.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided an environment where service users and relatives felt able to complain. Not all staff had received training in the protection of vulnerable adults from abuse and the policies and procedures in place that support this. Recruitment processes lacked robustness and this could place service users at risk. EVIDENCE: The homes complaints policy was on display in the entrance and staff were aware of how to record and action complaints. Recorded complaints were minor in nature and were addressed appropriately. Service users spoken to stated they would complain to the manager and the majority of surveys from service users stated they knew who to complain to or who to speak to if they were unhappy. All four surveys from relatives stated they had not had to make a complaint. Not all staff within the home had received training in the protection of vulnerable adults from abuse and staff surveys indicated that some were unsure of the adult protection policy and procedure in place to support this. Several staff including the manager had completed training by the local authority. The home had policies and procedures in place and the senior staff members spoken to were aware of what to do if they suspected abuse had Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 17 occurred. The manager was aware of how to refer any allegations to the lead agency responsible for investigation. The homes recruitment practices must be improved to make sure staff members are recruited in a way that protects service users and ensures that appropriate documentation is in place prior to the start of employment. See the section on staffing. Westdene Residential Home DS0000000875.V295622.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a clean and comfortable environment for service users. EVIDENCE: Generally the home was well maintained and homely in appearance. Since the last inspection the dining room had been redecorated and new flooring had been laid in downstairs corridors and two bedrooms. The home had a basic record of redecoration but a rolling plan of redecoration and work to be completed in the coming months needs to be identified. Communal space consisted of two lounges, a quiet area on the first landing and a dining room set out with individual tables and chairs. Service users could access an enclosed garden and a further patio area. A tour of the building showed that the home was clean and tidy and there were sufficient toilets and bathrooms around the home. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 19 Bedrooms had been personalised to varying degrees and service users confirmed they were able to bring in small items to decorate their room. All bedrooms had lockable facilities and keys were available. Generally the doors did not have privacy locks although the care file evidenced that service users were asked during admission if they required one. The homes laundry consisted of three washing machines and two driers and was locked when not in use. Generally infection control measures were in place although it was noted that one of the toilets had a towel for hand drying and this was a source of cross infection. The home must ensure all communal hand-washing areas have paper towels to prevent the spread of infection. Service users spoken to commented, ‘it’s a clean home, you can bring little things in’, ‘my clothes are marked, they are always washed and ironed nicely’, ‘oh yes my bedroom is cleaned’. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had sufficient numbers of staff to support service users within the home and a very high percentage of care staff had completed appropriate national vocational training. Deficiencies in the homes recruitment processes could place service users at risk. EVIDENCE: The home had sufficient staff on duty throughout the day and night, although some surveys received thought there were staff shortages at times, ‘they are short staffed now and again’, ‘sometimes it takes a while to answer bells’. The inspector received very postive coments about staff from service users and relatives. ‘the staff treat me like family’, the staff are not bad really, they look after us well, the staff are alright, I have no grumbles at all. The home had five staff in the morning, four in the afternoon/evening and two at night. The manager and deputy manager were supernumerary. There was a low staff turnover and those spoken to clearly enjoyed their jobs and knew the service users well. There was genuine warmth and affection noted between staff and service users. They were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote equality and diversity. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 21 Recruitment processes used to employ staff must be improved. Four new staff files were examined and in three cases two references were in place. One only had one reference. The manager had misunderstood guidance on criminal record bureau checks and in three cases had accepted the checks used from the staff members last employment. Criminal record bureau checks are not portable and checks to the protection of vulnerable adults register must be made prior to all staff being employed. The manager must ensure that criminal records bureau checks and povafirst checks are made for the new staff and stringent supervision arrangements put in place until satisfactory criminal records checks are returned. Staff induction was clear and comprehensive. New staff members worked through tasks and information linked to skills for care standards. Evidence of progress was produced and signed off by senior staff or the manager. The home maintained records of staff training and there was evidence of participation in mandatory training and service specific. A log was maintained of training completed and information given to the inspector indicated that the percentage of care staff having completed national vocational qualifications in care at level 2 and 3 was high at 70 . This was a very good achievement indeed and reflected the level of commitment from proprietors, managers and care staff. It was noted that some people had not completed moving and handling training, basic food hygiene, health and safety, adult protection and first aid and some updates in these were required. In discussion staff reeled off a variety of training courses they had attended and felt they were well trained for their roles. Specialist training in dementia care, managing challenging or distressing situations, diabetes care and incontinence management had been attended by some people. All staff who administered medication had completed an accredited medication course, all had completed fire training and all staff had watched a video on adult protection. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 22 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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home was managed well and maintained a safe environment for service users and staff, however deficiencies in staff supervision and individual risk management could place service users at risk. The expansion of the quality assurance process would capture a larger section of views about the services the home provides. EVIDENCE: The homes proprietor/manager had retired from their role as manager and one of the assistant managers recently completed registration with the Commission for Social Care Inspection to take over as the registered manager. The new manager had worked in social care settings for eighteen years and had completed a National Vocational Qualification in care in 2004 and the Registered Managers Award in 2005. Staff members spoken to were Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 23 complimentary about the manager and their style of management, ‘there is a relaxed atmosphere and the morale is good’, ‘she is approachable and sorts out problems’. All staff surveys indicated that they received support and direction from the manager although one person did feel that the mode of staff discipline could be improved upon to ensure confidentiality. Service users spoken to and surveys received from them were equally complimentary, ‘she’s been absolutely fabulous to me. They have really helped me and are trying to get me so I can go home’. The home had a system of staff supervision whereby senior care staff supervised each other and care staff. Ancillary staff members were supervised on a day-to-day basis. The manager checked supervision records but did not actually provide one to one supervision for staff. It was important for senior care staff to be supervised by their line manager and not each other to show clear guidance, decision-making and monitoring of their work, and how they supervise care staff. Records indicated that some care staff were not on target to receive six sessions a year and one care staff had not received any supervision. The home had a quality assurance system that consisted of questionnaires and some audits and they had been awarded Part 1 and Part 2 of the local authority Quality Development Scheme for care planning and quality monitoring systems. However the quality assurance system could be improved to ensure that a wide range of people commented on the services provided by the home. At present the same questionnaire is sent to relatives and professional visitors and there is no individual questionnaire for service users. The manager confirmed that relatives tended to fill in the relatives survey with service users, however some people would be able to fill in their own service user survey. Service user surveys could include questions on how and if staff promote privacy, independence and dignity and how staff treat people. Records indicated that feedback from professional visitors was low, however this could be addressed by ensuring the questionnaire to professionals contained relevant questions. The staff survey could include their views about induction, training, supervision and overall management of the home. The audits were completed on accidents, medication, care files, staff training, cleaning rotas and service user information, for example the statement of purpose and service user guide. The manager confirmed they did not complete an environmental audit but relied on staff to indicate when maintenance problems occurred. Service users finances were managed appropriately and individual records maintained. Monies held on behalf of service users were stored securely and receipts obtained for any personal shopping completed for them. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 24 Generally the safety and welfare of service users and staff were managed within the home, although there were some areas noted during the site visit that needed to be addressed. One service user had bedrails that were not fitted correctly as per manufacturers instructions. These were sorted out whilst the inspector was in the building. One service user had tipped backwards in their wheelchair twice and attempted to do this in their dining chair. An immediate requirement was issued for the manager to risk assess within 48 hours and take steps to minimise the risk, which they subsequently did. One service users call bell was not working, which was reported to the maintenance person. Fire alarms and equipment were checked and drills carried out monthly. Equipment was serviced and maintained. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 25 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 X X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 3 X 2 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement The registered person must ensure that the home obtains service users assessments completed by care management. The registered person must ensure that care plans reflect dementia care needs identified at the assessment stage with clear tasks for staff in how they are to support someone with dementia. The registered person must ensure that a risk assessment is completed with steps to minimise risk for a specific service user with regards to tipping backwards in their wheelchair and dining chair. Immediate requirement issued. The registered person must ensure that the home has documented systems in place to monitor service users unable to weight bare, as the home does not have any sitting scales. The registered person must ensure that records are maintained of activities participated in and that DS0000000875.V295622.R01.S.doc Timescale for action 08/12/06 2 OP7 15 31/12/06 3 OP8 13 04/11/06 4 OP8 12 31/12/06 5 OP12 16 31/12/06 Westdene Residential Home Version 5.2 Page 27 6 OP18 13 7 OP19 23 8 OP26 13 9 OP29 19 10 OP29 19 11 OP30 18 12 OP33 24 stimulation takes account of service users current capabilities and is tailored to meet individual needs. The registered person must ensure that all care and ancillary staff receive instruction on adult protection policies and procedures and whistle blowing procedures and are aware of what to do if they suspect abuse has taken place. The registered person must ensure that the home extends the maintenance record to indicate future plans for rolling redecoration. The registered person must ensure that hand wash facilities in communal areas have paper towels to prevent cross infection. The registered person must ensure that when recruiting staff two references are obtained and povafirst checks are in place prior to the start of employment. Stringent supervision to be in place if staff are employed after the povafirst check and before the return of the CRB. The registered person must ensure that criminal record bureau checks are completed for the new staff that have been employed recently with checks provided from previous employment. Povafirst checks to be initiated and stringent supervision put in place. The registered person must ensure that a training plan is produced that indicates training planned for the coming months to address shortfalls in mandatory training and updates. The registered person must ensure that the quality assurance system is expanded DS0000000875.V295622.R01.S.doc 31/01/07 28/02/07 31/12/06 08/12/06 08/12/06 31/12/06 31/03/07 Westdene Residential Home Version 5.2 Page 28 13 OP36 18 14 OP38 13 15 OP38 13 16 OP38 13 and questionnaires addressed to capture a wide range of views on the services provided by the home. Results of surveys must be displayed for service users and a copy forwarded to CSCI. The registered person must ensure that senior care staff receive formal 1-1 supervision from their line manager at least six times a year. First supervision session to have taken place by timescale for action date. All care staff to receive up to six sessions per year. The registered person must ensure that all service users call bells are in working order. Accidents must be audited and issues of health and safety identified and addressed quickly. The registered person must ensure that wheelchair services are contacted regarding safety issues affecting one service user. Immediate requirement issued. The registered person must ensure that bed rails are fitted as per manufacturers instructions and that staff receive training in how to fit them. 31/12/06 08/12/06 04/11/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP24 Good Practice Recommendations Privacy locks to doors should be fitted as standard when bedrooms are vacated. Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Westdene Residential Home DS0000000875.V295622.R01.S.doc Version 5.2 Page 30 - 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!