Inspection on 04/10/05 for Westerham Place

This inspection was carried out on 4th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westerham Place 10/02/09

Westerham Place 10/07/07

Westerham Place 23/01/07

Westerham Place 31/05/05

Westerham Place 26/08/04

Westerham Place 14/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Westerham Place Quebec Square Westerham Kent TN16 1TD Lead Inspector Jo Griffiths Announced 4 October 2005 09:30 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. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westerham Place Address Quebec Square Westerham Kent TN16 1TD 01959 565805 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) Yewcare Limited Mr Scott Bryn Ernest Davies CRH Care Home 24 Category(ies) of OP Old age (24) registration, with number of places Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/05/2005 Brief Description of the Service: Westerham Place is a care home providing personal care and accommodation for 24 older people. The home is located on the outskirts of the small town of Westerham, which has a selection of shops, pubs, a post office and churches. The home consists of a large detached two-storey building with a newer purpose built two-storey extension. All the home’s bedrooms are single with en-suite facilities, including a WC, wash hand basin and bath. In addition there is one assisted bathroom located on the ground floor. There is a large lounge surrounded by a conservatory and a separate dining room. All areas of the home are accessible to people who have limited mobility; there is a lift to the first floor. The home employs care staff 24 hours a day. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. The Manager and a number of staff and residents were spoken with. Some records were inspected. Comment cards were received from 8 residents, 2 GP’s and 1 relative. What the service does well: What has improved since the last inspection? 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. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 6 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 Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 7 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, 2, 3, 4 Residents are given the information they need about the home and have agreed a contract. They have their needs assessed before they move in. Residents know that their health and personal needs will be met but do not feel their social needs are adequately addressed. EVIDENCE: The Statement of Purpose and Service User Guide are presented as one document. This has been updated to include the complaints procedure and how the home meets residents’ religious needs. The Manager was advised that the contract residents sign does not accurately reflect the home’s liability insurance. All residents have an assessment of their needs to ensure they can be met by the home. It is recommended that the Manager ask a dementia nurse to review the needs of one resident. The Manager may need to review the care for this person following this assessment. Residents said that they feel their personal and health needs are well met but their social needs are not fully met by the home. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 8 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 Residents have a care plan that meets their health and personal needs. Their social needs are not planned for. Residents are not fully protected by safe medication practices. Residents’ privacy and dignity are maintained. EVIDENCE: Residents’ care plans are detailed and meet their health, personal and emotional needs. Social needs are not adequately planned for. All staff follow the care plans and the senior staff review them at least monthly. The local GP visits the home weekly. The Manager said that residents could choose the GP they register with. Medication is stored safely. Some staff are trained in medication, although the Manager needs to provide evidence that this is competence based training. All staff who administer medication must be trained to do so. Residents said that their privacy is respected and staff treated them with respect. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 9 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, 14, 15 Residents do not have access to the activities they would like. They are able to receive visitors when they wish. Residents are supported to make choices in most areas of their lives. Most of them enjoy the food but they would benefit from consultation about their preferences. EVIDENCE: Most residents said that they are not satisfied with the activities provided within the home and the Manager needs to consult with them on this matter. Residents said that they could receive visitors when they wish and see them in private. Residents said they would like to choose what time they get up in the morning. The manager agreed to review this. The chef is highly qualified and provides a very varied and high quality menu. Most residents were very complimentary about the food, however, some said that it can be too “fussy” and they would prefer simpler meals of the style they are used to at home. Residents choose their meals for the forthcoming week and some said they forget what they ordered. It is recommended that residents are involved in planning the menu. It is also recommended that the Manager review the way residents are informed of the choices that are available. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 10 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, 17, 18 Residents know how to make a complaint and know that their views will be listened to. They are supported to maintain their legal rights but are not fully protected against potential forms of abuse. EVIDENCE: The home has a clear complaints procedure and this is included in the Service User Guide. The complaints log showed that 2 small complaints had been received by the home and these had been responded to effectively. There is an adult protection policy in place, but staff have not completed training in adult protection. The Manager has not applied for a new CRB disclosure for all staff. The Manager said that residents can vote by post in all elections and generally family members supported them to self-advocate. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 11 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, 20, 21, 22, 23, 24, 25, 26 Residents live in a safe and comfortable environment. They have access to plenty of communal space, bathrooms and bedrooms that meet their needs. Residents are not provided with adequate furniture for their rooms. The home is very clean and hygienic. EVIDENCE: The home continues to be maintained to a high standard. The Manager said that all bedrooms are redecorated and carpets replaced before a new resident moves in. Residents have access to a large lounge/conservatory and dining room. All bedrooms are single with an en-suite bathroom and a call point. There is an additional bathroom on the ground floor that people with mobility difficulties can use. The Manager stated that residents could bring in their own bedroom furniture. The home must provide furniture to all service users unless they wish to bring their own. One resident said they would like more lighting in their room as they have difficulty with their sight. The home is kept very clean and laundry is managed with care. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 12 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, 28, 29, 30 Residents are not fully protected by safe recruitment procedures. They are supported by sufficient numbers of staff to meet their needs but will benefit from further training for staff. EVIDENCE: Sufficient staff are employed to meet the needs of the residents. The Manager stated that approximately 50 of staff had achieved their NVQ award. Certificates were not available to verify this. These should be made available for the next inspection. The Manager acknowledged that staff training requires improvement. Staff have completed some training, but the following areas should be addressed as a priority; first aid, manual handling, Infection control, POVA, health and safety and fire safety. An in-house induction is completed with new staff. This does not meet the standards set by the national training organisation “skills for care”. Staff files were inspected and some files did not contain 2 written references, a health declaration, a recent photo or a CRB applied for by the home. On the day of the inspection, staff who were working were patient, caring and aware of individuals’ needs. Residents said that the staff are pleasant and polite. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 13 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) 31, 32, 33, 35, 36, 37, 38 Residents live in a home run by an experienced Manager. They are consulted on their views of the home. Residents’ finances are not fully protected. Residents are kept safe. EVIDENCE: The Manager has a management qualification and is planning to complete the NVQ4 in care. Recently questionnaires were issued to residents and the feedback received about the home was positive. The Manager must ensure that these questionnaires can be completed anonymously. It is recommended that the residents’ meetings be set up again. Residents’ money is all kept in one account. This practice must be reviewed so that their money is not pooled. Residents are protected by health and safety policies and an environmental risk assessment has been completed. The home does not dispose of clinical waste appropriately. Equipment and facilities within the home are maintained and serviced. Staff supervision has not yet started. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 14 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 3 3 2 x 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 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 4 3 4 3 3 2 2 4 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 1 2 3 2 x 2 1 3 2 Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 15 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. Standard OP9 Regulation 13 (2) Timescale for action The registered person shall make 30/11/05 arrangements for competency based training to be provided to all staff who administer medication to clients. This requirement was set at the last inspection and has been partially met. Evidence of the training and that it is competence based must be forwarded to CSCI. 2. OP12 OP4 OP7 16 (2n) The registered person shall, 30/11/05 having regard to the size of the care home and the numbers and needs of the service users, consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard for the needs of the service users, activities in relation to recreation, fitness and training. In that, the Manager must consult with the service users and agree an appropriate timetable of activities for the Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 16 Requirement home. This should be regularly reviewed in consultation with them. 3. OP14 12 (2) The registered person shall, so far as practicable, enable service users to make decisions with respect to the care they are to receive and their health and welfare. In that, Service users must be offered a choice of when to get up in the morning. 4. OP18 13 (6) The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. In that, all staff should complete training in adult protection 5. OP24 16 (2c) The registered person shall, having regard to the size of the care home and the numbers and needs of the service users, provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings, and equipment suitable to the needs of the service users and screens where necessary. In that, furnishings, as detailed under Standard 2 of the National Minimum Standards, must be provided to all service users unless they choose not to use the furniture provided by the home. 6. OP30 18 The registered person shall, H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 17 30/10/05 30/11/05 30/11/05 Westerham Place OP38 (1)(c)(i) 13 (3)(4)(5) 23(4)(d) having regard to the size of the care home, the statement of purpose and the numbers and needs of the service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform, including structured induction training. In that, (a) all staff must complete an induction to the standards defined by the National training Organisation. (b) Staff must undertake training in the following areas as a minimum, 1st aid, Infection control, Health and Safety, Manual Handling and fire safety. The Manager is to provide an action plan to CSCI 7. OP35 20(1a) 30/10/05 The registered person shall not pay money belonging to any service user into a bank account unless the account is in the name of the service user or any of the service users, to which the money belongs. In that, service users money must not be pooled. 8. OP38 16(2)(k) The registered person shall, having regard to the size of the care home and the number and needs of service users keep the care home free from offensive odours and make suitable arrangements for the disposal of general and clinical waste. In that, Clinical waste must be disposed of safely. 30/11/05 Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 18 9. OP29 19(1)(b) The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in schedule 2. In that, the following must be obtained before staff start work at the home, (a) CRB disclosure applied for by the care home. (b) Health declaration (c) Recent photo (d) 2 Written references, 1 of which should be from the most recent employer. 30/10/05 10. OP25 23(2)(p) 30/11/05 The registered person shall, having regard to the numbers and needs of the service users, ensure that ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by the service users. In that, service users should be consulted to ensure they have adequate lighting in their bedroom. 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 OP31 Good Practice Recommendations The Manager should complete the NVQ4 care. H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 19 Westerham Place This recommendation has been carried forwarded from the previous inspection. The Manager has enrolled on the course. 2. OP2 It is strongly recommended that contracts with service users should be amended to accurately reflect the position of the home regarding liability and the insurance in place for such circumstances. It is recommended that the needs of the service user whose needs have changed be assessed by an appropriately qualified person. It is recommended that service users be consulted about the menu and how they would like to make their daily choice. It is recommended that the residents meetings be set up again. It is recommended that residents who require support to complete quality surveys for the home or for CSCI should be offered that support from an independent person to ensure anonymity. 3. OP3 4. OP15 5. 6. OP33 OP33 7. Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Westerham Place H56-H06 S24042 Westerham Place V244464 041005 Stage 4.doc Version 1.40 Page 21 - 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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