Inspection on 17/01/06 for Westerleigh

This inspection was carried out on 17th January 2006.

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

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

Other inspections for this house

Westerleigh 21/10/08

Westerleigh 10/10/06

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 Announced Inspection 17th January 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.V263243.R01.S.doc Version 5.0 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.V263243.R01.S.doc Version 5.0 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.V263243.R01.S.doc Version 5.0 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 19th August 2005 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 years 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 centre of town. 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 small seating area at the rear of the home that overlooks a patio area and there are two additional patio areas, one in the centre of the building with some residents rooms leading directly onto it, and one at the side, that 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. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection of the year and should be read in conjunction with the first inspection that was carried out on the 19th August 2005 to give an overview of all the standards assessed during this period. This was an announced inspection. The home was informed of the date and time of the inspection several weeks before it was carried out. The plan for this inspection was developed from the information provided in the pre-inspection questionnaire completed by the manager, and the comment cards completed by the resident’s relatives or representatives. The aim was to assess if the requirements listed in the last report had been met, assess the standards that were not assessed in the previous inspection, identify aspects of the service that have improved and how the service could be developed for the benefit of 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, for the purpose of this report those living at Westerleigh will be referred to as residents. The inspection was carried out over 7 hours by two inspectors commencing at 10.00. It included a tour of the home, an examination of care plans, personnel files, training records, policies and procedures, menus, medication charts and activities. There were 29 residents in the home during the inspection. The manager, administrator, training co-ordinator, cook, activity person and staff on duty were happy to discuss the care and support provided at Westerleigh. What the service does well: Residents are encouraged to regard Westerleigh as their home, some sit in the lounges while others remained in their rooms, watching TV or reading. Those who expressed an opinion said that they were given the support they need, staff were equally positive and felt they are able to provide appropriate care. Three visitors were happy with the care their relatives receive and felt involved in decisions about their day-to-day living. Residents were comfortable and relaxed with communication between residents, visitors and staff friendly and open. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 6 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. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 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.V263243.R01.S.doc Version 5.0 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): 1, 3, 4 and 5. Standard 6 is not applicable. The Statement of Purpose and Service Users Guide enable prospective residents and their representatives to make an informed decision about the homes ability to provide appropriate care and support. A pre-admission assessment is carried out for all prospective residents prior to the offer of a room. However these do not clearly define all the needs of residents, therefore staff may not be able to provide appropriate care and support on admission. EVIDENCE: A Statement of Purpose and Service Users Guide have been developed and are now available for current and prospective residents. A pre-admission assessment is completed for all prospective residents, prior to the offer of a room, to ensure that the home can meet their needs, and there have been some improvements. However it was noted that some preadmission assessment forms did not include all the necessary information, which will enable staff to provide appropriate care on admission and use them as the basis of the residents care plan. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 9 The staff confirmed that residents and their relatives are encouraged to visit the home to look at the rooms available and discuss the services provided. Relatives spoken with said that they had looked at a number of homes before deciding that a room at Westerleigh was the most appropriate, one stated that ‘this is the best home we found when we were looking for a nursing home’. Residents can stay at the home on a trial basis if they wish before they decide to stay on a permanent basis. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 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 the following standard(s): 7 and 8 There is no clear and consistent care planning system in place to adequately provide staff with the information to meet resident’s needs. EVIDENCE: A considerable amount of work has been carried out to ensure that the care planning system enables staff to provide appropriate nursing care and support. Staff training has been provided and there have been improvements in the recording of relevant information. However it was noted that the information available concerning resident’s needs is not consistent and care plans are not all reviewed on a regular basis. The manager and senior staff at the home are aware that there are some deficiencies and further training, with assessment of competence, will be developed for the registered nurses. Nutritional assessments are used more effectively, with weight loss and gain measurements to assess the needs of residents. Staff spoken with were able to demonstrate an understanding of the residents individual needs and how these are addressed, although this information is not recorded in all the care plans. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 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, 14 and 15. Residents benefit from a varied programme of activities, based on their preferences and interests. EVIDENCE: The programme of activities has been improved and a number of individual and group activities are provided. The activity persons on the day of the inspection offered a range of activities, morning and afternoon, which included quiet time with individuals and a group singing session. A record is kept of the activities that are provided and the residents who choose to participate. The staff spoken with were able to demonstrate an understanding of residents likes and dislikes and there was evidence that the activities are planned accordingly. The staff confirmed that residents are encouraged to make choices about all aspects of their day-to-day living, this was supported by the residents themselves and their relatives. Some residents prefer to remain in their rooms, while others join in activities, depending on what is provided, and what else is planned for their day with many receiving visitors in the morning or afternoon. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 12 Snacks and drinks are available throughout the day, lunch was sampled and found to be appetising with residents and relatives saying ‘the food is very good’ and ‘there is always a choice’. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 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 and 18 Appropriate policies and procedures concerning complaints are in place to protect residents. Adult Protection training is provided to ensure residents are protected from abuse. EVIDENCE: There have been no complaints since the last inspection. Appropriate policies and procedures are in place. Residents are registered to vote and take advantage of the postal voting system if they wish. Adult Protection training is provided, this includes types of abuse, what action should be taken if staff have any concerns, and whistle blowing. The manager and training co-ordinator confirmed that all staff have attended this training, which commences at induction and continues through the foundation course and the NVQ programmes that some staff are following. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 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): 22 and 24 Residents are supported appropriately with an effective and accessible call bell system in place to summon staff when required. EVIDENCE: Westerleigh provides comfortable, homely individual and communal space. There are attractive gardens to the rear and side of the building as well as an internal patio area, accessible to wheelchair users and directly by some residents from their rooms. Some work is still required in the garden area and internally, such as covering hot pipes, to ensure that the environment is safe for residents and their visitors. Residents have access to the call bell system in their own rooms if appropriate, and there are call bells in the lounges. Staff confirmed that they remain with residents when they are in the lounges so they are aware if residents require assistance, particularly as some residents are unable to use the call bell. It was confirmed that risk assessments identify that it is inappropriate for locks to be available for resident’s rooms. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 15 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): 30 There is a broad range of training available for staff, which enables them to provide appropriate support and care for residents. EVIDENCE: An extensive ongoing training programme has been developed by the training co-ordinator, which commences at induction and continues through to NVQ qualifications. Over 50 of the care staff at Westerleigh are trained to NVQ Level 2 or above. The manager and training co-ordinator confirmed that training will now concentrate on the registered nurses with opportunities for them to develop professionally. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 16 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, 35, 36, 37 and 38 The manager is supported well by staff, with staff demonstrating an awareness of their role and their responsibilities when providing care and support for residents. The systems for resident consultation are good with evidence that residents and relatives views are sought and acted upon. Formal supervision provides appropriate support for staff, which ensures that residents receive the care and support they need. EVIDENCE: The manager is a registered nurse, she has been the owner and manager at Westerleigh since 1999 and has completed the NVQ Level 4 in management. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 17 The manager advised that a registered nurse has recently been appointed deputy manager of the home, and the expectation is that some of the managers responsibilities will be delegated to the deputy. A quality assurance and monitoring system has been developed to assess all aspects of the services provided at Westerleigh. Questionnaires have been used to obtain feedback from residents and their representatives. This has now been developed to include information about service provision generally and will be used to develop a business plan on a yearly basis. The home does not take responsibility for the finances of residents. Some residents manage their own money while others are supported by relatives or solicitors. Informal supervision is provided as part of the day-to-day management of the home. Training has been provided to enable staff to provide formal supervision, and this is now in place. The homes policies and procedures have been reviewed and updated as required and are now sufficient to meet the NMS. Training required by legislation is provided for all staff and includes manual handling, fire training, first aid and health and safety. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 18 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 3 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X 3 X 3 X X 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 3 X 3 X 3 3 3 3 Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP4OP3 Regulation 14 (1)(2) Requirement Timescale for action 06/03/06 2 OP7 15 3 OP7 18 (1)(a) 19 (5)(b) 4 OP8 12 (1)(a) Pre-admission assessments to reflect the needs of residents. This is outstanding from 27.01.05. Documentation in relation to 06/03/06 each resident to be collated to ensure the care plans comprehensively outline their individual care needs and meet the criteria outlined in Schedule 3. This is outstanding from 27.01.05. Appropriate training to be 06/03/06 provided to enable staff to complete residents care plans and ensure the records reflect the nursing care provided. This is outstanding from 27.01.05. Nutritional assessments to be 06/03/06 completed for all residents and reviewed on a regular basis. This is outstanding from 27.01.05. Westerleigh DS0000014077.V263243.R01.S.doc Version 5.0 Page 20 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.V263243.R01.S.doc Version 5.0 Page 21 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. 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