Inspection on 12/09/05 for Westerlands Care Centre

This inspection was carried out on 12th September 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

Westerlands Care Centre 29/01/09

Westerlands Care Centre 30/01/07

Westerlands Care Centre 02/03/06

Westerlands Care Centre 08/03/05

Westerlands Care Centre 30/09/04

Westerlands Care Centre 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Westerlands Care Centre Elloughton Road Brough East Yorkshire HU15 1AP Lead Inspector Sarah Sadler Unannounced 12 September 2005 10:00 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. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westerlands Care Centre Address Elloughton Road Brough East Yorkshire HU15 1AP 01482 667223 01482 667223 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) Prime Life Limited Mrs Alice Bott Care Home 35 Category(ies) of DE(E) Dementia - over 65 35 registration, with number OP Old age 35 of places PD(E) Physical dis - over 65 35 TI(E) Terminally ill 35 Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8.3.05 Brief Description of the Service: Westerlands Care Centre is a large house situated in its own spacious grounds in a residential area of the village of Brough. The village itself has numerous shops, a train station and is adjacent to a motorway. Accomodation is provided over 3 floors serviced by a lift. The home is owned by Prime Life Ltd. The home may provide residential and nursing care for up to 35 people of either sex, who may also suffer with dementia, a physical disability or terminal illness. Service users health and persoanl care needs are met with access to other professionals, for example the chiropodist, as necessary. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day by one inspector, with a previous two hours preparation time. The inspection was part of the annual inspection programme from April 1st 2005 to March 31st 2006. During the inspection a tour of the premises was undertaken, service users, relatives and members of staff were spoken to. A large amount of time was spent with service users, observing their everyday life. Some time was spent reading service user and other records within the home. What the service does well: What has improved since the last inspection? What they could do better: All service users should be issued with terms and conditions for living in the home, ensuring people are fully aware of any rules (and regulations). This is subject to differing interpretation between the registered provider and the Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 6 CSCI and legal advice is being sought. This requirement may therefore be subject to amendment. Evidence that the electrical wiring is safe and that service users are not being put at risk must be provided. Evidence that the local fire authority have agreed the use of door wedges should be provided. A total of 50 of the staff team should be qualified to NVQ level 2 or equivalent. 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. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,6 Not all service users receive full information prior to moving into the home. Service users are assessed prior to moving into the home, to ensure that the home can meet their needs. EVIDENCE: Service users who are self-funding continue to be issued with a contract regarding the ‘rules’ for living in the home. Details of conditions of residence should be provided also to service users who are funded by a Local Authority to ensure they are aware of the terms of their residence. This is subject to differing interpretation between the registered provider and the CSCI and legal advice is being sought. This requirement may therefore be subject to amendment. Service user files included a copy of a Social Services care plan that has been replaced by the homes own assessment and care plan. These care plans are reviewed monthly. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 9 The deputy manager confirmed that the home does not provide intermediate care. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Service users’ health and personal care needs are met. Privacy and dignity is upheld. EVIDENCE: Each service user has an individual plan of care that details their personal needs. The plan of care addresses a variety of areas including mobility, communication, sleeping and physical well being. Service users or their relatives have signed the plans to confirm agreement, this includes agreement to their preferred times for getting up and going to bed. Risk assessments are in place for risk of developing a pressures sore, nutrition and moving and handling. One visitor confirmed that whenever they visit “people’s personal care needs are always met”. The GP confirmed, “Residents are always clean and tidy, even when they are not able to do this themselves”. One relative confirmed, “The home gets the GP to see to him” “ I have seen them taking people to do dressings and things”. A GP confirmed, “ I am very happy, the home is quick to pick up on any health needs, and quick to call the GP, they provide a high standard of nursing care and overall I am very happy Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 11 with the way the home is run and the residents looked after. The basic nursing is excellent”. Care plans include details of other professionals involved with the service users, for example, the chiropodist, and details of any visit by the GP with the reason and outcome for the visit. One service user confirmed that “I see the doctor if I need to”, another confirmed “I am seeing the doctor on …. The home arranged it”. One visitor confirmed that their relative receives their medication “ Oh yes, they fetch it whilst I am here”. There is a medication policy and records are kept of all medicines entering, administered and leaving the home. The disposal of medicines is currently being reviewed due to new legislation regarding such disposal. Controlled drugs are stored appropriately with up to date records kept. There is a lockable medication fridge, of which daily temperatures are taken and recorded. Staff spoke respectfully to service users, for example” do you mind if I just move you a little bit? – Thank you”. Service users confirmed that staff respect their privacy. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 12 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 Service users are able to make choices in their lives, this includes choosing a variety of activities, when to receive visitors and what to eat. Service users nutritional needs are met. EVIDENCE: During the inspection a volunteer was visiting service users to chat and if service users wished complete bible readings. The volunteer stated, “They do lots of activities, for example, memory work. There’s a big effort from the staff, they have a Christmas and Summer Fayre, I attend with the choir at Christmas”. A member of staff confirmed that a variety of activities are undertaken, for example, a quiz, baking, dominoes, draughts and snakes and ladders. One service user stated, “ they take me on trips, I went to Lavender fields last week and I am going to the circus “. Service user notes reflected that service users attend differing activities and may choose whether they wish to participate in an activity. One relative commented about visiting “ I come every day, lunchtime until about 6.45” The volunteer confirmed “visitors are always coming and going”. A staff member confirmed, “ Visitors come and go”. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 13 A staff member confirmed that service users make choices in their daily lives “service users choose what they want to wear, what they wish for tea, what they want to drink”. Service user notes reflected that service users may make choices, for example, “ came down for lunch today”. Service users are supported to make decisions in their lives, for example, one service user asked a member of staff what they thought would be suitable to wear for a forthcoming trip out. One service user also confirmed that they preferred that someone of the same gender undertook support for personal care and that this was provided by the home. Also that they could: “ Have my room as I like”. One relative commented about the food “ Food is good, they never have to wash up after him.” The volunteer confirmed, “The food is wonderful, food that is required to be is mashed or specially done”. “ There are always clean cloths on tables, they are immaculate”. A service user stated, “ Meals are very good, very nice”. Service users are able to have their meals either in the dining room or in their own rooms. One service user ate their lunch in their room and was able to have their own supply of condiments, for example, brown sauce. The dining areas are divided into two, both being pleasantly set out. Two relatives were able to assist their relative with the eating of their meal and staff were available to assist service users as required. One member of staff stood over a service user whilst assisting them to eat and this was discussed with the deputy manager. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Service users are able to complain and feel that their complaints will be acted upon. Service users are protected from abuse. EVIDENCE: One relative confirmed, “Anything bothers you, you go straight to them and tell them. Alice is marvellous. Nothing is too much trouble to them.” They also commented “ I have never had anything that upset me at all”. A service user confirmed that if they wished to complain they could and that the registered manager was “More like a friend”. Another service user confirmed that they felt able to complain and that there complaint would be addressed. “ Oh yes, fortunately that doesn’t occur”. There is a complaints procedure in the home and a complaints book to record the outcome of any complaints. There are no recorded complaints since 2003. There is a copy of the Local Authorities policy ‘ The Protection of Vulnerable Adults’ held within the home. Although no formal training has been undertaken regarding this the staff member interviewed was confident in the appropriate actions to take should an allegation of abuse occur. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 Service users live in a clean, comfortable and hygienic home. EVIDENCE: An annual audit of the home is undertaken with a list being compiled of all major works to be completed over the coming year. Some of this work has commenced in the home for this year, with some new carpets. One visitor commented, “It is always clean”. The compliments book included “Very nice home, very clean”. A GP confirmed, “ The rooms are always clean and tidy”. One service user confirmed that their room was always kept clean and that they received a clean towel and flannel every day. There is a policy for the handling of clinical waste and the actions to take in the event of a spillage. Protective clothing is provided. There is a separate laundry facility within the home. There is a letter held in the home confirming that all necessary works to meet the Water Supply (Water Fittings) Regulations 1999 have been completed. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Service users needs are met by sufficient staff that are appropriately deployed and trained. EVIDENCE: One relative confirmed, “Yes, there are enough staff”. Another visitor stated, “As far as I am concerned there are enough staff”. One service user stated “oh yes, there is always someone to help” and that when they rang their buzzer someone always came to assist. Duty rotas reflected that each day there are ten staff between the hours of 7 am and 9 pm, who work a variety of shifts in order to support service users, with a further three staff between the hours of 9 pm and 7am. This reflected a total of 596 care hours, a reduction from the inspection of September 2004 when 707 care hours were provided. There is a copy of the General Social Care Council (GSCC) code of conduct for staff. Staff files included confirmation of a Criminal records Bureau check, two references and an application form. If required evidence of a work permit was also available. The staff member confirmed that they had undertaken a variety of training over the last year “ COSHH, Moving and Handling, and Fire”. The deputy manager confirmed that the NVQ training is ongoing and that although the home had achieved the target of 50 of the care staff trained to NVQ level 2 or equivalent some of these staff have now left. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 17 Training records reflected that over the past year 8 staff have completed Moving and Handling training, 12 staff have completed Fire Training, 12 staff have completed risk assessment training, 13 staff have received customer care training. One staff has undertaken COSHH training, 4 have completed First Aid training and 3 have completed Food Hygiene training. There is a training plan for the staff team for the coming year. There was no evidence that staff have received training specific to the needs of service users with dementia. The deputy manager confirmed that the home continues to provide mentorship to overseas nurses and that this is via the University of Hull. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38 Service users and their representatives are able to contribute to the running of the home. Service users’ health, safety and finances are on the whole well managed. EVIDENCE: There continues to be a quality assurance system held within the home that seeks the views of service users and relatives. A report is published from the findings of this. Records are kept of any service users’ finances held within the home. Receipts are kept of all purchases made and these records are regularly checked. The home does not handle any service users’ personal bank accounts or allowances. When communal purchases are made the receipts are stored in one service users’ records only. The need to be able to track all purchases was discussed at the inspection. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 19 There are a variety of policies and procedures held within the home. These include Fire, Smoking, Grievance, Health and Safety, and accidents. Regular servicing has been undertaken on the lift, hoist, bath hoist, and fire equipment. Portable appliance (PAT) testing has been completed. No evidence was available that the electrical wiring meets the requirements and the deputy manager confirmed that the electrical wiring in the home has yet to be assessed as safe, and a member of staff is being trained by the organisation in order to complete this. There are risk assessments that include, fire, COSHH and asbestos. Records of any accidents are recorded and a RIDDOR book is available. There is a fire risk assessment in the home, this was completed in August 2004 and has no plan of the home attached. Some doors were being held open by unauthorised means and the deputy manager confirmed that this was after discussion with the local fire brigade and that these means are only utilised when staff are near to or in the room. The written agreement of the fire and rescue service regarding this must be provided. Hot water outlets tested were near to 43 degrees centigrade. One staff call was found not to be working in the bathroom and the deputy manager was made aware of this at the inspection. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 20 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 x 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 1 Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 21 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 2 Regulation 5 Requirement The registered provider should ensure that all service users are issued with a contract/statement of terms and conditions for residing in the home. The registered provider must ensure documentary evidence that the electrical wiring within the home meets the appropriate requirements. This requirement has been brought forward from the last inspection with a previous timescale of 30/11/04. The registered person must ensure that the staff call system works in all rooms. The registered person should ensure documentary evidence from the local fire authority, of authorisation of the use of door wedges. Timescale for action 30/09/05 2. 38 12 8/6/05 3. 4. 38 38 13 13,23 20/9/05 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 22 Westerlands Care Centre 1. 15,18,30 2. 3. 4. 5. 6. 7. 30 35 38 The registered person should ensure staff training includes;support for service users with the eating of meals, the handling of allegations of abuse and supporting people with dementia. The registered person should ensure that 50 of the staff team are trained to NVQ level 2 or equivalent by 2005. The registered perosnshould ensrue that all records are held individually. The registered person should ensure an up to date fire risk assessment with plans. Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 3 First Floor 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 Westerlands Care Centre 20050912 Westerlands Care Centre IR J53 v224575 s959.doc Version 1.40 Page 24 - 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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