Inspection on 12/12/05 for Westerley

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Westerley 06/06/06

Westerley 15/06/05

Westerley 14/10/04

Westerley 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westerley The Esplanade Grange-over-Sands Cumbria LA11 7HH Lead Inspector Mrs Margaret Drury Unannounced Inspection 12th December 2005 10:30 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 Westerley DS0000022667.V262819.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. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westerley Address The Esplanade Grange-over-Sands Cumbria LA11 7HH 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) 015395 32408 The Leaders of Worship and Preachers Homes Mrs Elizabeth Lynne Davey Care Home 29 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (29) of places Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 29 service users to include: up to 29 service users in the category of OP (Older people, not falling within any other category) up to 4 service users in the category of DE(E) Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 15th June 2005 2. Date of last inspection Brief Description of the Service: Westerley is owned by The Leaders of Worship and Preachers Homes, a registered charity, trading under this name. It is run on a day-to-day basis by Mrs Elizabeth Lynn Davey. Westerley is situated near the centre of Grange-over Sands overlooking Morambe Bay. The building, which was formerly an hotel, is an older property that has been adapted and extended for its present use as a care home. Accommodation for residents is on three floors that are served by a passenger lift and two small stair lifts. The rooms are mostly for single occupation but there is a married couple living in one of the double rooms. There are en-suite toilets and washbasins in all the rooms with seven also have showers. There are two lounges and a dining room. The home is equipped to assist people with disability. There is a well-kept garden and a parking area at the rear of the building. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one morning. It was the second inspection of this year and the standards not assessed on this occasion were assessed and met on the previous visit that took place earlier in the year. During the inspection, time was spent with the manager looking at care plans and other records to do with the running of the home and care of the residents. The inspector was able to speak with residents, deputy manager and staff and some parts of the home were looked at. During the visit the inspector spoke with one of the volunteer staff, attached to the organisation, that visits the home each month to conduct an internal quality audit and inspection. What the service does well: What has improved since the last inspection? Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 6 Refurbishment of the dining room is now complete and other internal redecoration is on going, with the hallway being the latest part of the home to be finished. The home has recently purchased a supervision and appraisal package, a new set of policies and procedures and training package from a firm of independent consultants, all of which are proving to be of benefit to the staff and residents. 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. Westerley DS0000022667.V262819.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 Westerley DS0000022667.V262819.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 & 5 Residents benefit from an in-depth admission process that assists them to make a decision about whether or not to move into the home. EVIDENCE: The home has a detailed statement of purpose that gives sufficient information to enable an informed choice to be made about whether or not to move into the home. Prospective residents and their families are invited to visit the home for refreshments and/ or a meal prior to admission, in order to meet the staff and those already living in the home. This helps them to decide whether or not the home is able to meet all the assessed needs. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 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, 9 & 11 The systems for the administration of medication are good, with clear and comprehensive arrangements in place to ensure service users’ medication needs are met. Residents benefit from a care planning system that ensures their needs are met in a way that promotes their privacy, dignity and independence. EVIDENCE: The home has an excellent care planning system and the inspector was able to examine a number of care plans during the visit. They were found to be very informative, with details of the care needs, healthcare visits/appointments and a moving and handling assessment. Reviews were up to date. The arrangements for storing and administering medication in the home were safe and well organised, and residents received their medication as prescribed, with records kept. The manager or deputy completes a weekly audit of the medication records as an added safety precaution. The policy for handling the death of a resident is clear with residents’ wishes recorded on the care plans. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 10 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 & 15 Residents benefit from being able to express their wishes about how to spend their time and are given the choice about whether or not to join in any organised activities. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: All the residents are able to express their wishes about how they like to spend their day and those who spoke with the inspector said they were “able to do what they wanted”. As Westerley is run on Christian principles there is a devotional period every day, which all residents attend. As many residents are physically frail there is now a service every Sunday afternoon for those not able to attend their own church. Activities of the residents’ choice are organised by the staff and all the Christmas entertainment has been planned. Some residents are able to go out to the shops and/or the library and one lady attends a weekly art group. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 11 The home operates a 6-week menu with a choice at each meal. This is a vegetarian option that has proved very popular with those residents who are not solely vegetarian. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 12 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): 17 & 18 Staff understood adult protection issues, which protected residents from abuse. EVIDENCE: Discussions with the manager evidenced that those residents who wish to, are encouraged to take part in the electoral process, either by voting in person or via the postal voting system. Staff who spoke with the inspector showed an awareness of adult protection issues and an in-house training course in the subject is currently being prepared by one of the assistant managers. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 13 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): 21, 22, 23 & 25 Residents benefit from a well maintained warm and friendly environment in which to live. EVIDENCE: All of the residents’ rooms have en-suite facilities and there are also sufficient communal bathrooms and toilets for the residents’ use throughout the home. The refurbishment of the dining room has now been completed and the residents who spoke with the inspector said how lovely the room looked. The home has specialist equipment for those residents that have a physical disability. These include, handrails on corridors, assisted bathing, raised toilet seats and hoists. All of these facilities ensure the residents live in safe, comfortable and suitable surroundings. Residents’ bedrooms were bright, warm and nicely furnished. They all contained personal items that the residents had brought from their own homes. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 14 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): 28 & 29 Residents are cared for by a staff team that is well trained and appointed following a rigorous recruitment process. EVIDENCE: There is a full complement of staff, some of whom are trained to NVQ level two. There were three members of care staff on duty on the day of the inspection, an assistant manager, deputy manager and the manager who has recently returned to work after surgery. These staff plus the cook and domestic staff were able to attend to peoples needs, keep the home clean and provide meals and snacks during the day. The home has a full recruitment and selection process and no new staff are appointed until all the legal checks have been completed. These measures contribute to the protection of the residents. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 15 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, 34, 36 & 37 The manager has a clear vision and development plan for the home, which she effectively communicates to the service users, staff and relatives. EVIDENCE: The registered manager has recently returned to the home after a period of sick leave and those residents that spoke with the inspector expressed their pleasure at her return. Discussions with her confirmed her commitment to giving the highest level of care to the residents. She works closely with the staff team to ensure all the assessed needs are met. She has considerable experience in the care of older people and during the inspection demonstrated clear lines of responsibility and delegation to the senior care team but also provided a “hands on approach” when necessary. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 16 The home has a full set of policies and procedures in place that have recently been written for the home by a professional training company. As regular updates are received this will ensure that they are always up to date. Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 17 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 315 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 X X 3 3 3 X 3 x STAFFING Standard No Score 27 X 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 X 3 3 x Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 Westerley DS0000022667.V262819.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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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