Inspection on 19/08/05 for Westerleigh

This inspection was carried out on 19th August 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

Westerleigh 21/10/08

Westerleigh 10/10/06

Westerleigh 17/01/06

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 Unannounced 19 August 2005 09:00 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. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westerleigh Address 18 Corsica Road Seaford East Sussex BN25 1BD 01323 892335 01323 892667 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) Regency Medicine Mrs Carolyn Whelan Care Home with nursing 31 Category(ies) of Old age, not falling within any other category registration, with number (OP) 31 of places Physical disability (PD) 31 Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The maximum number of service users to be accommodated is thirty-one (31). 2 That service users are sixty-five (65) years and over on admission. 3 That service users with a physical disability can be accommodated. Date of last inspection 27 January 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 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 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 H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The requirements from the previous inspection report and the findings in subsequent visits were used to develop the plan for this unannounced inspection. The aims were to assess if the home had met the requirements, identify the aspects of the service that had improved and how the service could be developed for the benefit of the residents. The inspection was carried out over six and a half hours by two inspectors and started at 9am, it included a tour of the building, to speak to residents who remain in their own rooms and enable an assessment of the facilities, an examination of care plans including risk assessments, medication charts, staff files, residents contracts and policies and procedures. There were 25 residents in Westerleigh during the inspection and there were opportunities to talk to residents, visitors, the care staff, the cook, the training co-ordinator, the administrator and the manager about the care provided for residents. There were no organised activities on the day, although there is a programme of activities and the expectation was that something had been arranged for the afternoon of the inspection. What the service does well: What has improved since the last inspection? A considerable amount of work has been done since the last inspection and a number of requirements have been met. The resident’s terms and conditions have been reviewed to ensure that all the relevant information concerning costs are included. Staff are following the homes medication procedures. There are choices provided for each meal and the cook could demonstrate a good understanding of their preferences. Appropriate training in Adult Protection and Whistle Blowing has been provided for staff and policies and procedures have been reviewed. The maintenance of the home is ongoing with plans to replace carpets and redecorate now that the building work on the extension has been completed. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 6 The home was clean, with hazardous waste bins emptied and sluice rooms locked. A thorough recruitment procedure is now in place and includes POVA/CRB checks and two references prior to the offer of employment. 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 H59 H10 S14077 Westerleigh V229578 190805 stage4.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 Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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) 1, 2, 3 and 4. Standard 6 is not applicable. A pre-admission assessment is carried out for all prospective residents. However these do not clearly define the needs of residents, therefore staff are unable to provide appropriate care and support on admission. EVIDENCE: The statement of purpose has been reviewed and updated and the indication was that it would be available for current residents, prospective residents and their representatives in the near future. A service users guide will be developed when this has been completed. The terms and conditions and contract for residents has been reviewed; it now identifies the additional payments that may be required if resident’s needs change and the room number that has been offered and accepted. A pre-admission assessment is completed for each prospective resident but those viewed did not contain a complete picture of their needs. The manager stated that she had asked all relevant questions but there was no evidence to support this and staff would not have access to this additional information if the manager were not in the home. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 9 The manager advised that the home could meet the needs of older people and individuals with physical disabilities, with each prospective resident assessed before a room is offered. However the home can only show capacity to meet the assessed needs of residents if the pre-admission assessment provides a complete picture of their needs. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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 and 9. There is no clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. The staff are protecting residents by following the homes procedures with regard to the administration of medicines. EVIDENCE: A considerable amount of work has been done to introduce an effective care planning system. Training has been provided for staff and the recording of residents needs and the care provided has improved. However, it was noted that the information available varies with care reviews; risk assessments and nutritional assessments are not completed for all residents on a regular basis. The difficulties of developing a care planning system were discussed with the manager and highlighted the need for an appropriate pre-admission assessment, with a regular review of the residents assessed needs and the involvement of the residents and their representatives as an essential part of this process. Residents are registered with GP’s and have access to allied health professionals if required. Residents are weighed regularly and it was noted that some have lost or gained weight. The staff explained that there were problems Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 11 with scales designed for use with a hoist and therefore inaccurate readings may have been taken, these scales are no longer used. Weight loss and gain is an additional tool that can, when used with a nutritional assessment, enable staff to provide an appropriate diet for each resident. The trained staff are following the homes procedures in the administration of medicines and signing the medicine administration record (MAR sheets) appropriately. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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 and 15. Residents would benefit from a varied programme of activities, based on their preferences and interests. There is little evidence that residents are encouraged to exercise choice and control over their lives, consequently residents do not benefit from a fulfilling lifestyle. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: A programme of activities is advertised in the home, however there was no evidence that an activity had been arranged on the day of inspection, despite the staff believing that something had been organised. There were no clear indications that the residents’ interests and hobbies are used as the basis for the activity programme and there was no evidence to show that residents are offered a varied schedule of activities each day depending on their preferences. There is open visiting at Westerleigh and several residents had visitors on the day of inspection. The staff indicated that residents are encouraged to make choices about all aspects of their day and some supported this view explaining that they choose to spend their days in their own rooms. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 13 However, it was noted not all residents are able to make these choices. Two were seated in a lounge area that is quite noisy, which made talking to them difficult as one has hearing difficulties. The TV had been switched on even though neither resident requested this and although one member of the care team identified that a resident would like to listen to music he did not have the time to organise this. Residents should be encouraged to make choices about all aspects of their day-to-day living, including the care they receive. Relatives and friends can be a useful resource for obtaining information about the residents’ preferences and if used effectively may enable staff to encourage residents to exercise control over their lives, if appropriate. This holistic approach to providing care and support for residents was discussed in detail with the manager and the administrator as it had been indicated that decisions about what is best for the residents are taken by the staff and appear to be based on the needs of the home not the needs of the residents or their visitors. Choices were available for the meals, the cook discussed the individual residents likes and dislikes and showed a good understanding of their dietary needs. Snacks and drinks are available throughout the day and assistance is provided if required. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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) EVIDENCE: These standards were not assessed. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment within this home is satisfactory providing residents with an attractive and homely place to live in. All parts of the home are safe and accessible with satisfactory infection control systems in place to protect residents and staff. EVIDENCE: The building work on the extension to the north of the home is now completed with four additional rooms and two lounges that are available for residents to use. The original part of the home now requires updating and redecoration; this is planned as part of the ongoing maintenance programme and will include new carpets. Westerleigh provides comfortable and homely individual and communal space. There are three lounges, two at the front and one at the rear of the home that do not meet the National Minimum Standards (NMS) regarding minimum communal space for residents. However, the available space has been used to provide a quiet lounge, a larger lounge for group activities and a smaller bright area that overlooks the rear patio. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 16 There are three attractive patio areas, one to the side, one at the rear and one internal area that is accessible from some resident’s rooms. They are accessible to wheelchair users and are used by the residents when the weather permits. A shaft lift enables residents to have access to all parts of the home and there are hoists, assisted toilets and baths, which ensure that residents are able to use the facilities with the support of staff. There is one shared room and 29 single rooms in the home. Residents are encouraged to personalise their own rooms and many have done so with ornaments, pictures and small pieces of furniture. The rooms are furnished by the home with adjustable beds, bedside cabinets, wardrobes, tables and armchairs, although residents can bring larger pieces of furniture to the home with the agreement of the manager. Emergency lighting is provided throughout the home and call bell systems are provided in all rooms used by residents. It was noted that access to a call bell was not provided in one of the lounges, the expectation is that all residents have access unless a risk assessment identifies that this is not appropriate. The home was clean and there are systems in place to prevent the spread of infection. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 17 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 and 30. There are sufficient trained and competent staff on duty at all times to meet the assessed needs of residents. Thorough recruitment procedures help to ensure the safety and protection of residents. EVIDENCE: The trained nurse was sick on the day of the inspection; the manager was therefore covering for her on the morning shift. The manager advised that sufficient staff were on duty to meet the needs of residents although it was noted that staff tended to talk to residents only when they were providing care or assisting at meal times. The staffing levels at the home have been discussed during previous inspections and monitoring visits, with the levels based not on the number of residents in the home but on ensuring that there is sufficient staff on duty to meet the assessed needs of residents. The homes recruitment procedure is followed and includes a POVA/CRB check and two references prior to the offer of employment in the home. New members of staff are able to start their induction training, under close supervision, when a POVA check has been completed but will not be able to provide personal care until the CRB check has been received by the home. All staff receive induction training in line with TOPSS (Skills for Care) as well as the mandatory training required, including manual handling and fire safety. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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, 36 and 37. Residents would benefit from a more structured and formalised system of staff supervision. EVIDENCE: A working group, which includes the manager and a number of care staff, has been set up to look at the services provided at Westerleigh. The aim is to develop appropriate policies and procedures, as well as an effective quality assurance and monitoring system and there are plans to involve the registered nurses when the clinical aspects of the service are reviewed. As Westerleigh is a nursing home and the registered nurses are responsible for the care provided the expectation is that they would be involved in all decisions about the services at the home. Informal supervision is provided in the home as part of the day-to-day management, however a system to provide formal supervision has not been developed although the training co-ordinator has completed a training course which enables her to provide supervision for the care staff. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 19 The homes policies and procedures are to be reviewed and updated as part of the process to develop an appropriate quality assurance system. Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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 2 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x 3 2 x Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.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 OP 1 Regulation Requirement Timescale for action 30.09.05 2. OP 3 & 4 3. OP 7 4. OP 7 5. OP 8 6. OP 12 Schedule1 A statement of purpose and Regulation service users guide to developed 4&5 and made avaiable to current and prospective residents. This is outstanding from. This is outstanding from 27.01.05. 14 (1)(2) Pre-admission assessments to reflect the needs of residents. This is outstanding from 27.01.05. 15 Documentation in relation to each resident to be collated to ensure that the cre plans comprehensively outline their individual care needs and meet the criteria outlined in Schedule 3. This is outstanding from 27.01.05. 18 (1)(a) Appropriate training to be 19 (5)(b) 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. 12 (1)(a) Nutritional assessments to be completed for all residents and reviewed on a regular basis. This is outstanding from 27.01.05. 16 (m)(n) A revew of activities provided to be carried out to ensure all residents have opportunities to H59 H10 S14077 Westerleigh V229578 190805 stage4.doc 30.09.05 30.10.05 30.10.05. 30.10.05 30.10.05 Westerleigh Version 1.40 Page 22 7. OP 12 12 (2) 16 (2)(m) 8. OP 14 12 (2)(3) 9. OP 22 13 (4)(c) 10. OP 24 13 (4)(c) 11. OP 33 24 (1) 12. OP 36 18 (2) 13. OP 36 18 (1)(c)(i) 17 14. OP 37 participate in groups, or individually, based on their capabilities and preferences. This is outstanding from 27.01.05. The routines of daily living, including social activities to be flexible and varied to meet residents preferences. This is outstanding from 27.01.05. Residents to be given the opportunity to exercise autonomy and choice in all aspects of care and support provided at the home. This is outstanding from 27.01.05. Residents to have acces to a call bell system unless a risk assessment identifies it is inappropriate. This is outstanding from 27.01.05. Risk assessments to be completed for the provision of locks for doors to residents rooms. This is outstanding from 27.01.05. Quality assurance and monitoring system to be developed and introduced. This is outstanding from 27.01.05. A formal system of supervision to be developed and introduced for all staff on a regular basis. This is outstanding from 27.01.05. Approprate training to be provided for all staff responsible for supervision. This is outstanding from 27.01.05. Policies and procedures to be reviewed and updated. This is outstanding from 27.01.05. 30.10.05. 30.10.05 30.09.05 30.09.05 30.11.05 30.11.05 30.10.05 30.11.05 Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 23 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 Good Practice Recommendations Westerleigh H59 H10 S14077 Westerleigh V229578 190805 stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex 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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