Inspection on 24/01/06 for Westdene Residential Home

This inspection was carried out on 24th January 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

Westdene Residential Home 25/10/07

Westdene Residential Home 02/11/06

Westdene Residential Home 13/09/05

Westdene Residential Home 22/07/04

Westdene Residential Home 03/03/04

Similar services:

Snydale Care Home

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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 Angela Sizer Unannounced Inspection 24th January 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.V263731.R01.S.doc Version 5.1 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.V263731.R01.S.doc Version 5.1 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 Ms Margaret Every 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.V263731.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide personal care to one service user, named on the CSCI file, who is under pensionable age. 13th September 2005 Date of last inspection Brief Description of the Service: Westdene is a large and extended Victorian House on Alliance Avenue off Anlaby Road offering personal care and accommodation for up to 30 elderly people with a broad range of needs including dementia. A sole trader owns the home and that person is the registered provider and the registered manager. The home is on two levels with a person carrying lift connecting the floors. Service users are accommodated in 26 single rooms (15 are en-suite) and only 2 double rooms. There are three lounges, eight toilets, three bathrooms and one shower. The home has a small rear garden/patio and is only a short bus ride to the city centre of Hull. The home has it’s own car park. Many local facilities are within walking distance, shops, chemist, GP surgery, pubs and a money bingo, to name some. Personal care is provided, assistance with mobility and independence is given, and efforts are made to involve the service users in as many activities as they wish. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 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 6.5 hours. Preparation for the inspection took two hours. A sample of records relating to the residents, staff and general running of the home were looked at. Three residents and three staff files were examined. A tour of the premises was carried out. Ten residents were spoken to and two staff were interviewed in private in relation to the running of the home and what the care was like. The assistant manager helped with the inspection, feedback was given throughout the inspection process. The inspector would like to thank the residents, staff and manager for their help and hospitality during this inspection. What the service does well: What has improved since the last inspection? Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 6 All of the recommendations from the previous inspection report have been met. Since the last inspection the home has implemented nutritional assessments and if any special dietary needs are required, then a referral to the nutritionist is made. Nutritional screening is detailed in each care plan for residents. The complaints procedure has been updated and now includes timescales. Fire drills are recorded on a monthly basis. 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 DS0000000875.V263731.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 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 the following standard(s): 5 Prospective residents have the opportunity to visit and assess the quality and suitability of the home prior to moving in. EVIDENCE: During the visit relatives were spoken to about what the procedure had been for moving into the home, they stated; “we visited the home without my mother as she was unable to come along, as soon as we came in it felt homely and comfortable”. Residents confirmed that they had been able to visit the home, meet the staff and other people who live there, one person said, “I came and had a meal and talked with the staff”, “they made me feel welcome”. Staff who were spoken to confirmed that whenever possible residents are visited at their home’s and an assessment of need undertaken, they are also invited to visit the home and enjoy a meal or overnight stay prior to making a decision as to whether they wanted to move in permanently. The home does not offer intermediate care. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 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 the following standard(s): 8,9 & 10 Residents’ health care needs are fully met. It is recommended that the medication procedure be amended to ensure the safety of the residents. Residents’ who are ill or dying receive support with sensitivity and respect. EVIDENCE: Since the last inspection the home has introduced a nutritional assessment that is undertaken upon admission, this is to ensure that all dietary needs are recorded and is situated in the resident’s file. If any special dietary needs are noted then a referral is made to the health service nutritionist, who then visits the home and offers further advice and assessment. All other health care checks continue to be undertaken on a regular basis. The medication system is the NOMAD and on the whole the recording is of a good standard, one gap was found during the inspection and any medication that is not required is returned to the Pharmacist on a weekly basis. The home has a medication policy and procedure in place and there is also a homely remedies policy that has been endorsed by a local GP this includes lemsip, imodium, simple linctus. There is a separate controlled drugs cabinet and a controlled drug register, currently one resident is receiving Temazepam and Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 10 although this is not a controlled drug it is recommended as good practice that it be administered and recorded as one. During the inspection it was observed that staff treat residents’ with respect and courtesy, speaking to them directly and ensuring that choice was given. Assistance was offered to some residents at lunch time and again this was carried out ensuring that the individual was helped in a enabling way. Two relatives were spoken to also confirming that staff always offer assistance in an appropriate manner, “we are totally satisfied with the care offered and all of the staff are helpful to us and the residents”. From speaking to two staff members about how the death of a resident is dealt with, it was evident that the support offered would not differ from what was always offered, care would be given in a respectful and dignity maintained throughout this difficult period. Relatives are welcome to stay with their loved ones for as long as they would need to, refreshments are offered etc. Some of the staff have undertaken training in relation to loss and bereavement and they could describe what procedure would need to be undertaken in the event of a sudden death of a resident. A visiting district nurse was also spoken to about the level of care offered at Westdene. She stated that the staff are always on hand to help and listen to the instruction given by the District Nursing team, she also said that the home are quick to react when a resident is deteriorating and they contact the nursing team immediately. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 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 the following standard(s): 14 & 15 Residents are enabled to make choices on a daily basis therefore promoting their independence. A healthy, nutritious and diverse menu is offered. EVIDENCE: During the inspection two relatives were spoken to about the care offered and whether relationships are supported and maintained they described the home’s staff as “really friendly”, and the “management couldn’t be more helpful, any problems are sorted quickly”. They also stated that they are welcome to visit at any time and there are no restrictions upon this, they are always offered refreshments and biscuits and the resident’s privacy is respected. Control and choice are also promoted and any restrictions are detailed within the resident’s individual care plan and risk assessment. Staff were observed throughout the day carrying out their duties in an enabling and positive manner ensuring that they described to the resident what was happening. Two staff were interviewed as part of the inspection process confirming that they had a sound knowledge and understanding of the specific needs of the residents. They stated, “privacy is always respected, I knock before entering anyone’s bedroom, I always explain what I am doing even if the resident has limited speech, the home believes in promoting independence and choice”. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 12 The home operates a four-week rotating menu and this is displayed on the notice board in the hallway. Several of the residents said that the quality of food offered was very good, some comments included; “the food is lovely”, “I always enjoy the food and the cooks are very good”, “if you don’t like something then the staff know to ask you what else you would like”. Visiting relatives stated, “the food always looks very appealing and smells very nice”. Lunch consisted of steak casserole, cabbage, mashed potato, carrots and swede with gravy, dessert was chocolate sponge and custard. An alternative was available and this is discussed with the residents on a daily basis. Tea was going to be cheese pie or scrambled eggs with a variety of sweets including fruit or yoghurt. The meal was well presented, appealing to the eye and plentiful. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 13 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 & 17 The home has a complaints procedure, which meets the needs of residents who feel their views are listened to. Residents’ legal rights are protected and they are enabled to take part in the electoral process. EVIDENCE: Since the previous inspection the home’s complaints procedure has been updated and this now includes a timescale of 28 days. From speaking to relatives and residents it was clear that any issues whether minor or more serious are listened to and acted upon, there had been no complaints since the last inspection. During discussion with the assistant manager it was explained that all residents who are able to do take part in the electoral process, some use their postal vote. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 14 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): 19,20,21,22,23,24,25 & 26 The environment is homely and comfortable; some areas require attention in order to ensure that cleanliness and safety standards are maintained. Residents’ individual bedrooms are personalised and homely. The home has sufficient communal toilets and bathrooms to meet the needs of all residents. A malodour was detected in the hallway and dining room, the remainder of the home was clean and hygienic. EVIDENCE: A tour of the premises was undertaken and on the whole the home was clean and hygienic, it was unfortunate that a malodour was present in the hallway and dining room and this remained throughout the day as this let the rest of the home down. The carpet in the hallway was worn and had wrinkled up in places and this could pose a trip hazard to the residents or staff. The dining room requires redecoration as paint was noticed peeling off the walls and skirting boards. The carpet in the Link corridor require attention, again it was wrinkled and worn and could pose a risk. All of the resident’s bedrooms were individual, clean and personalised, some comments from residents included, “I Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 15 really like my room, it is cosy”, “I have brought some of my furniture and pictures”. There are sufficient communal toilets and bathrooms both assisted and nonassisted in meeting the needs of all of the residents. The home has 16 bedrooms that are en-suite. There is a laundry room that consists of 2 industrial washing machines, 2 industrial dryers and 1 domestic style washing machine. The home employs a laundry assistant for 7 hours per day and good infection control procedures are in place. There is a wash-hand basin and the floor and walls are impermeable. From discussion with the assistant manager it was identified that the home does not currently have a maintenance plan and work is undertaken as and when required. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 16 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): 28 Well-trained staff support residents. EVIDENCE: During the inspection it was apparent that staff receive a good level of training including all of the mandatory training such as fire safety, health and safety, moving and handling, infection control, protection of vulnerable adults, first aid and food hygiene. In addition to these staff have undertaken more specialised training in relation to other age related illnesses. More than 50 of staff have now obtained NVQ level 2 or 3 in care. From speaking to the staff it was clear that they have access to an array of training events and they confirmed that they feel well supported by the management of the home. One commented, “I have access to a variety of training including all of the mandatory, but other areas that I am interested in such as dementia care”. Residents are supported by a well-trained staff group who treat the residents with respect and humanity. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 17 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): 31,32,33,34,36 & 38 The management of the home is carried out with leadership and appropriate guidance; ensuring residents receive a quality of care and a resident centred ethos is promoted within the home. Resident’s financial affairs are safeguarded by the homes policy. On the whole the health and welfare of residents and staff are promoted and protected, however it was noted that the electrical wiring certificate was out of date and therefore the safety of the residents could have been at risk. EVIDENCE: The registered manager who is also the registered provider has many years experience in the care industry and is a qualified RGN. She has completed the Registered Managers Award. Both of the assistant managers have also undertaken NVQ level 4 in care and management. From speaking to both residents’ and staff it was evident that the manager operates an open door Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 18 policy offering support whenever necessary. Some comments included, “all of the managers are approachable”. There are clear lines of accountability within the home and with external management. The home takes care of residents’ personal allowance, written records are kept of all transactions and these were found to be up to date and accurate, also having staff signatures for each transaction. All monies and valuables are held in suitable secure facilities. Staff confirmed that they receive regular and consistent supervision and from perusal of records this was confirmed. Regular team meetings are held and recorded. On the whole the health and safety of the residents and staff are promoted and there are systems for safe working practices in place. It was noted that the electrical wiring certificate had expired in December 2005, the assistant manager did explain that they had contacted the electrical contractor who had not committed himself to a day. During the inspection the assistant manager contacted the electrical contractor and requested a time and date, he was going to undertake the electrical wiring check the next day on 25.1.06, a copy of the certificate is to be forwarded to the CSCI. All staff receive a thorough induction and foundation training within 6 months and on-going training as and when required. Records confirmed that training in relation to fire, health and safety, infection control, food hygiene, protection of vulnerable adults and moving and handling are all offered and up to date. The home has a fire policy and procedures are clear. Regular checks on the system are maintained and staff receive training, fire drills are now undertaken on a monthly basis and recorded separate to the fire testing. There is a fire risk assessment in place. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 2 3 3 x 3 3 3 2 STAFFING Standard No Score 27 X 28 3 29 x 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 X 3 x 2 Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP19 Regulation 12,13,16, 23 16,23 Requirement The carpets in the main hallway and the link corridor require replacement. The home must have a maintenance plan prioritising areas in need of redecoration or renewal with records kept. The home must be free from offensive odour. The home must have an up to date electrical wiring certificate Timescale for action 24/01/07 24/04/06 3 4 OP26 OP38 16,23 12,13,16, 23 24/04/06 24/02/06 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 OP9 Good Practice Recommendations Temazepam should be stored and recorded as a controlled drug. Westdene Residential Home DS0000000875.V263731.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, 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 DS0000000875.V263731.R01.S.doc Version 5.1 Page 22 - 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. 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