Inspection on 12/09/05 for Westerley

This inspection was carried out on 12th September 2005.

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

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

Other inspections for this house

Westerley 29/10/07

Westerley 14/11/06

Westerley 02/02/06

Westerley 07/03/05

Westerley 04/11/04

Westerley 15/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westerley 1 Winton Avenue Westcliff-on-Sea Essex SS0 7QU Lead Inspector Ann Davey Unannounced 12 September 2005 th 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. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westerley Address 1 Winton Avenue Westcliff-on-Sea Essex SS0 7QU 01702 349209 01702 213192 westcliffe@ipma.demon.co.uk Mutual Aid Homes 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) Position vacant CRH Care Home 24 Category(ies) of OP Old Age (24) registration, with number of places Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2005 Brief Description of the Service: Westerley is registered to provide care and accommodation for 24 older people. Priority admission is given to local preachers and their dependants of the Christian and Wesleyan Reform Union Churches. The premises were converted from 2 hotels and was extended in 2001 and now provides comfortable accommodation. All rooms have ensuite facilities. There are 5 double rooms, which may be used as large singles. Some bedrooms have views of the Thames Estuary. There is a choice of 2 lounges and a separate dining area. There is a small patio area at the rear of the home. A prayer service with hymns takes place in the lounge each weekday morning. There is no off street parking and the driveway provides very limited spaces. The home is siuated close to the main shopping areas of Southend, Westcliff and Leigh on Sea. There are good bus and train links to the area. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a 6.5 hour period. The inspection focused mainly on the progress the home had made since the last inspection, although some other standards were considered. Not all the ‘shortfalls’ from the last inspection were re assessed. This has been reflected within the relevant ‘agenda for action’ section of this report. A partial tour of the home took place. Staff, residents and a visitor were spoken with. Records were selected at random and viewed. A notice was displayed in the main entrance area advising all visitors to the home that an inspection was taking place with an open invitation to speak with the inspector. The name/status of the registered provider has changed (due to internal changes within the organisation) and application to regularise this must be made to the Commission as soon as possible. The acting manager (Simon Lee) was present throughout most of the inspection. It was his day off, but on hearing that inspection was taking place, chose to be present. ‘Feedback’ was given during and at the end of the visit with opportunity for further discussion and/or clarification. What the service does well: What has improved since the last inspection? It was evident that the home has taken note of the shortfalls identified at the last inspection. Although many have not been addressed in full, they have been acknowledged and there is a commitment for move forward. Staff recruitment records and care planning documentation are now improved and attempts have/are being made to address staff training. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 6 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 I56-I06 S15484 Westerley V248990 120905 Stage 4.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 Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.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) 3 & 6 The pre admission assessment was adequate and identified care needs, which the home felt they could meet. EVIDENCE: Only one resident has been admitted since the last inspection. Although basic, the information obtained was adequate to form an initial admission assessment. The home is looking to developing recording systems. The home does not provide intermediate care. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 & 10 Care plans are basically adequate, but the current recording system(s), which includes risk assessments, is not conducive to clarity. This could result in staff not being clear about specific care needs and/or how they should be met. The home upholds residents’ rights of privacy and dignity. EVIDENCE: It was positive to note the progress the home has made since the last inspection. Although basic, care plans now identify care needs. Clearly the home has spent time on this. It was also positive to note that residents actively contribute in the planning of their care. The home continues to develop risk assessment documentation. Discussion took place with the acting and deputy manager concerning the current recording system. The inspector was advised that the home had already recognised the need to review the current recording system(s) and plans are under way to do this, which hopefully will result in a more structured, simplified system. At present, the system consists of various pieces of isolated relevant documentation, but there is no order, no one place of storage and this could lead to confusion. The home is committed to improving the system. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 10 Documentation demonstrated that residents have full access to all health care agencies. From practice observed on the day and residents comments, the home actively respects and upholds the values of privacy and dignity. The medication recording system identified some issues that need to be addressed. These matters were fully discussed with the acting manager. The medication storage system although not inspected, looked orderly and presented well. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 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 standard(s) Not inspected EVIDENCE: Not inspected Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 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 standard(s) 16 The home has a complaints procedure displayed in the main entrance. EVIDENCE: Residents confirmed that they would have no hesitation in raising any concern or complaint with a member of staff. The complaints procedure is displayed on the home’s notice board. The procedure provides details of the Commission, but it should also state that the Commission could be approached without any prior reference to the home. The home’s complaint record demonstrated that any complaint received by the home, is dealt with in an appropriate manner. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 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 standard(s) 19,20,23,24,25 & 26 The environment was clean, homely, comfortable and pleasant. Some infection control/safety issues need to be addressed for the wellbeing of both staff and residents. EVIDENCE: Residents’ bedrooms were very personalised and comfortable. Communal rooms were homely, well decorated and furnished. The home was clean with no unpleasant odours. Residents and the visitor spoke of the home being peaceful and happy. The issues identified at the last inspection concerning the poor/inadequate lighting within the dining area are being pursued. The home is to provide details of how this is to be addressed to the Commission as soon as they are available. There were however several issues that do need to be addressed by the home, these include: Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 14 • Wardrobes should be secured to bedroom walls or a risk assessment must be in place. Wardrobes are currently free standing and could potentially pose a risk if pulled on or used inappropriately by residents. The laundry area is also used for hairdressing and chiropodist services. There are serious potential infection control and safety issues in the area as it is used by staff, visiting professionals and residents. It is also used as a ‘through way’ to the rear garden area. At present, there are no infection control procedures, safe working practice assessments and/or risk assessments in place. This area contains electrical equipment, cleaning materials and COSHH items. In addition, washing waiting for attention was noted to be lying on the floor. This in itself posed a tripping hazard apart from being a poor infection control practice. Current practice within this area poses a serious risk of cross contamination/poor infection control/physical hazard. The home must take professional advice on how to manage the situation and take adequate measures. Residents are unable to control/regulate the heating in their respective bedrooms as radiator heating controls are ‘boxed in’. • • Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Staffing levels are adequate to meet the needs of current residents. Staff recruitment records met with regulatory requirements. Training must be further developed to enhance staff skill and competence. EVIDENCE: Current residents have low physical and mental dependency needs and the current staffing levels are adequate to meet identified care needs. It was noted that some staff continue to work 14-hour days. The acting manager said that this was being ‘phased out’ in due course. There were only 14 residents accommodated at the time of the inspection. It remains current practice within the home that only the acting manager has access to staff recruitment records. Therefore, upon initial request, these records were not available to the inspector as he was ‘off duty’. The home asked for the acting manager to attend the home. There is a statutory requirement that these records be made available at all times to the Commission. This practice was raised at the previous inspection and has not been addressed. Practice and options to meet this requirement were discussed with the acting manager. There was some confusion about the ‘requirement’ and this was fully discussed. Although records were eventually made available to the inspector, there remains a ‘requirement’ within the agenda for action for this matter to be addressed. Records of the most recently recruited members of staff were adequate. Staff confirmed that induction had taken place and was ongoing. Staff supervision Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 16 sessions have now been implemented. Staff said that communication within the home needs to be developed, and the acting manager has acknowledged this. Residents’ benefit from being cared for by a stable core group of staff and spoke of the kindness of staff in general. Staff were observed to be caring for residents in a sensitive, respectful manner. Staff wear practical, yet attractive uniform dress. At the last inspection, insufficient mandatory staff training was identified. This is being addressed by the home, but still remains inadequate. The home accommodates residents with diabetes and Parkinson’s disease, but no staff have received awareness training. Other mandatory training needs have been identified and are known to the acting manager. The home must fully review the situation and forward a comprehensive training programme to the Commission. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 17 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) 31, 33 & 38 The home is under control of new local management and new/revised management systems are being development and/or implemented. These changes once implemented and functional will enhance the service provided. EVIDENCE: The previous registered manager left her post earlier this year. Simon Lee is now the acting manager and has made application to the Commission for the position of registered manager. In addition, the name/status of the registered provider has changed (due to internal changes within the organisation) and application to regularise this must be made to the Commission as soon as possible. The acting manager is fully aware of the areas for development and improvement and is committed to addressing the shortfalls identified at this Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 18 inspection. He is aware that this inspection was only a ‘snap shot’, and is advised to audit all the standards associated with the category of registration. There are some safety, infection control and staff training issues which must be addressed without delay as these situations pose a potential risk to staff and residents. The overall management ethos of the home is for the care to be ‘resident centred’ and this was evident during the inspection process. Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 2 x x 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 3 x x x x 2 Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? Yes. Some have not been fully met although progress has been made. 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 7 Regulation 12,13 & 15 Requirement The registered person must ensure that all residents have a comprehensive care plans in place. They must include full risk assessements where appropriate. These documents must be reviewed on a regular basis and maintained in a manner which is condusive to clarity and ease of reference. This shortfall has been addressed in part since the last inspection. The registered person must ensure that all records are available for inspection as required by regulation. The previous timescale of 14/5/05 to meet this requirement has not been achieved. The registered person must ensure that staff are trained and competent in medication administration and recording procedures. The guidance provided by Royal Pharmaceutical Society must be I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Timescale for action 31/10/05 2. 29 17 & 19 31/10/05 3. 9 13 31/10/05 Westerley Version 1.40 Page 21 4. 19,20,26 & 38 13 followed and practice monitored. The home must also review their in house medication administration policies/procedures to ensure compliance with current guidance. The registered person must fully 31/10/05 assess the current situation within the laundry area and the purpose for with it is used. Advice about the suitability of the venue concerning the various activities that take place in this area must be sought and adequate risk assessments, safe working practice, and infection control documentaion must be in place and displayed. This area is used by staff, residents, visiting professionals and is a through way to the garden area. The registered person must also take adequate measures to ensure that residents are not placed at risk because of insecure furniture in bedrooms. The registered person must arrange and maintain a quality assurance system for reviewing and improving the quality of care provided. Although not assessed in detail, the acting manager advised that no progress on meeting this requirement from the last inspection has been made so far. The previous timescale of 1/10/05 made on 7/3/05 has been extended to 31/10/05. The registered person must identify what training is required and make suitable arrngements for all staff to receive the required mandatory training and other training associated with I56-I06 S15484 Westerley V248990 120905 Stage 4.doc 5. 33 24 31/10/05 6. 30 18 31/10/05 Westerley Version 1.40 Page 22 their work. This includes awareness training on diabetes and parkinsons disease. A review must be completed by 31/10/05. Full records must be kept and made available to the Commission. 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 27 Good Practice Recommendations The registered person should ensure that the continuing practice of some staff working 14 hours days ceases, unless no other options are available. This was raised at the previous inspection. The registered person should ensure that the text ..may approach the Commission without prior reference to the home/regsitered person be added to the current displayed complaints procedure. The registered person should ensure that residents are able to control the level of heating within their own bedrooms. The registered person should ensure that consultation continues and a resolution is found concerning the lighting in the dining area, hallway and lounge area. This will be reviewed at the next inspection. The registered person should ensure that there is no unecessary delay in providing the Commission with the documentation required concerning the change of name regarding the registered provider and the application in respect of a registered manager. 2. 16 3. 4. 20 & 25 19 5. 31 Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend-on-Sea SS2 6BG 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 Westerley I56-I06 S15484 Westerley V248990 120905 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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