Inspection on 10/10/06 for Westerleigh

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Westerleigh 21/10/08

Westerleigh 17/01/06

Westerleigh 19/08/05

Westerleigh 27/01/05

Westerleigh 13/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Westerleigh 18 Corsica Road Seaford East Sussex BN25 1BD Lead Inspector Kathy Flynn Key Unannounced Inspection 10th October 2006 10:00 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 Westerleigh DS0000014077.V312735.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. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westerleigh Address 18 Corsica Road Seaford East Sussex BN25 1BD 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) 01323-892335 Regency Medicine Mrs Carolyn Whelan Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (31) of places Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtyone (31) Service users must be older people aged sixty five (65) years or over on admission Service users with a physical disability can be accommodated. Date of last inspection 17th January 2006 Brief Description of the Service: Westerleigh Nursing Home is registered to provide nursing care for up to 31 residents, older people over the age of sixty-five and individuals with physical disabilities. The home is situated in a residential area close to the seafront on the western edge of Seaford and is approximately 30 minutes walking distance from the town centre. An extension has recently been completed at the north end of the building, which includes four rooms with en suite facilities and two lounges. There is a smaller seating area at the rear of the home that overlooks a patio area. In addition there are two patio areas, one in the centre of the building with some residents rooms leading directly onto it and one at the side. These are accessible to wheelchair users and are used when the weather permits. A shaft lift enables residents to access all parts of the building and there are appropriate aids, including hoists, to ensure the safe transfer of residents within the home. The fees for rooms at the home vary from £520 to £730. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on the 10th October, starting at 12.30, it took place over 7 hours. A pre-inspection questionnaire and 10 residents surveys as well as relatives comment cards and staff surveys were sent to the home. The pre-inspection questionnaire and two residents surveys and three comment cards were completed and retuned to the Commission. The inspection included a tour of the home, an examination of care plans, staff files, training records, policies and procedures, accident records and activity records. There were 26 residents at the home, all were spoken with and those who expressed an opinion were very positive about the support they receive at the home. The manager, the registered nurse, the training co-ordinator, the quality assurance co-ordinator, care staff and cook were happy to discuss the care they provide for residents. The reader should be aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the term service user to describe those living in care home settings. However for the purposes of this report those living at Westerleigh will be referred to as residents. What the service does well: What has improved since the last inspection? Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 6 All the requirements listed in the previous report have been addressed. Pre-admission assessments are completed prior to offering prospective residents a room at the home. This information is then used as the basis of the residents care plans, which enable staff to provide appropriate support and care for residents. Training has been provided for staff to ensure they have the skills to complete the care plans and complete relevant assessments. 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. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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 Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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): 3 and 4. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A pre-admission assessment is carried out, prior to the offer of a room, to ensure the home can meet the needs of prospective residents. EVIDENCE: Prospective residents and their relatives are encouraged to visit the home to look at the rooms, meet staff and assess the services provided. Pre-admission assessments are completed for all prospective residents prior to the offer of a room, this ensures that the home can meet their individual needs. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system provides staff with the information they need to meet the residents needs. The systems for the administration of medicines are good with clear arrangements in place to ensure residents medication needs are met. The staff have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between the staff and residents. EVIDENCE: A considerable amount of work has been done to improve the care planning system at Westerleigh Nursing Home. The care plans include risk assessments, including those for falls, nutritional assessments, moving and handling assessments, including the aids to be used, and daily records. There is evidence that they are reviewed on a regular basis, with the involvement of Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 10 relatives if they wish. Records are kept of any referrals to other health professional including GP’s. A registered nurse is responsible for ensuring that the care plans provide the information necessary for staff to meet the residents needs. She had identified an issue with the use of Body Mass Index and weights, and was planning to provide further training to ensure that these measures are used correctly. Staff were noted to treat residents with respect, encouraging them to make choices about how they spend their time. Some residents were sitting in the lounge while others remained in their own rooms. Medication is stored securely in the staff room. Staff were following the homes policies and procedures concerning its administration, with accurate recordings on the Medicine Administration Charts. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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): 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 has developed a range of group and individual activities, based of the residents preferences and interests, for residents to participate in if they wish. The routines of the home are flexible. This enables resident to have control and make choices about all aspects of their day to day lives. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The two activity staff have developed a programme of activities for residents which offers variety and choice. Activities organised includes painting, singing, exercises and quizzes, and is provided in groups or individually depending on the residents preferences. Residents who expressed an opinion were positive about some activities although some prefer to spend their time in their own rooms, to read or watch Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 12 the TV. The routines of the home were noted to be flexible and enabled residents to make choices. There is open visiting at the home, residents are encouraged to maintain contact with friends and relatives, who are invited to attend the residents meetings if they wish. A residents meeting had taken place on the morning of the inspection to decide how they are going to spend the vouchers they have from a local gardening centre. The meals provided at the home are varied and nutritious, residents said that ‘there is always a choice’ and the food is ‘very good’. The cook explained that ‘they can have what they like’ and ensures that they are offered home made meals, chocolate cake was made for afternoon tea. The meals looked attractive and residents were able to choose where to eat them, in the lounges or their own rooms. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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): Quality if this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted upon. Staff demonstrated a good understanding of Adult Protection issues, which protects residents from abuse. EVIDENCE: Appropriate policies and procedures are in place with regard to complaints. There have been no complaints made to the Commission since the last inspection, a relative raised some concerns but these were resolved following discussions with the manager. Feedback from residents and relatives confirmed that they are able to discuss any aspect of the care provided with the staff, and did not have concerns during the inspection. Feedback from residents was that they are ‘comfortable’, there is a ‘two-way dialogue about any concerns’ and ‘am very happy about the care of my relative’. Training in adult protection is provided for all staff. Those spoken with have completed the training and were able to demonstrate a good understanding of the prevention of abuse and the protection of vulnerable adults. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Infection control policies and procedures are in place and staff were able to demonstrate a good understanding of these. EVIDENCE: The standard of the environment at Westerleigh is good. Residents rooms are re-decorated when they are empty, one was being done during the inspection, and there are attractive and comfortable lounge areas for residents to use. Residents are able to bring some of their own possessions to the home and many have personalised their rooms with ornaments, pictures and small pieces of furniture. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 15 Policies for the control of infection are in place, training is provided for staff. Staff consulted were able to demonstrate an understanding of these. Residents who expressed an opinion said they found the home ‘very clean’ and tidy. However, a bed was stained and several were rusty and difficult to clean, therefore infection control cannot be assured. A review of the homes furniture is needed to identify which require repair or replacement. This should include commodes, bed tables and cabinets, baths and bath seats and would assist the home in being able to follow its own infection control policies. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing numbers and skill mix is appropriate to the assessed needs of residents. Training is provided for staff to ensure that the residents receive the care and support they need. EVIDENCE: The home has a stable staff team and some have worked at the home for several years. Comments made by residents and feedback from residents surveys complemented the staff on the support they provide, ‘difficult to find a better place’, ‘I am quite happy here’, ‘we chose Westerleigh for their considerate and calm help to the residents’, ‘staff are kind and positive’. The manager discussed the recruitment procedures and confirmed that POVA/CRB checks are completed prior to the offer of work, as well as two references and employment check. Some personnel files were examined and found to include the relevant information. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 17 NVQ training is provided for staff, the current percentage of qualified staff is 45 . This will increase significantly when those currently studying NVQ Level 2 and 3 complete this training. Induction training, in line with Skills for Care, is provided for all new staff. Those spoken with are using this training as an introduction to the NVQ Level 2, and are hoping to start this when they have completed the induction course. A training programme has been developed by the training co-ordinator and includes the training that staff must undertake by law. This includes moving and handling, food hygiene, first aid, fire safety and infection control. In addition the specialist training provided over the last year includes: nutrition assessments, mouth care, supplementary feeds, bowel care, management of constipation, care of ageing skin, catheterisation, continence care, wound care, dressings and stress awareness. A record is kept of which courses each member of staff has attended so that any updates and refreshers can be identified and arranged. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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 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, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is well supported by the staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Residents interests are safeguarded by robust policies and up to date records. A quality assurance and monitoring system, including regular staff supervision, enables the home to offer appropriate support and care. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager/owner of Westerleigh has been managing the home for a number of years, she is a registered nurse and has considerable experience in caring for older people and the physically disabled. The management style at the home is open and transparent. Residents, relatives and staff are encouraged to participate in deciding how the service is developed. A team of staff, which includes the manager, nurses and senior carers have been developing a quality assurance system to monitor the care and support provided at the home. Residents meetings and questionnaires are used in addition to daily discussions to assess the quality of the services offered. The manager, training co-ordinator, quality assurance co-ordinator and activity staff confirmed that any development of the service is based on the feedback from residents and relatives. The manager confirmed that the home does not take responsibility for residents finances, instead most residents are supported by relatives or other representatives. The homes policies and procedures have been reviewed and updated. The quality assurance co-ordinator will be looking again at these to ensure that they are appropriate to the residents at Westerleigh. Formal supervision is provided for all staff, in addition to the supervision that is part of the daily management of the home. Training has been provided to enable staff to offer appropriate supervision. Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 21 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 OP26 Regulation 13 (4)(a) Requirement Furniture in the home to be assessed, repaired or replaced, to ensure that the home follows its infection control policies. Timescale for action 26/02/07 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 Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Westerleigh DS0000014077.V312735.R01.S.doc Version 5.2 Page 23 - 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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