CARE HOMES FOR OLDER PEOPLE
Westerley The Esplanade Grange Over Sands Cumbria LA11 7HH Lead Inspector
Margaret Drury Unannounced 15 June 2005 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 F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Westerley Address The Esplanade Grange Over Sands Cumbria LA11 7HH 015395 32408 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) LPMA Homes Elizabeth Lynne Davey Care Home 29 Category(ies) of OP - Old Age registration, with number DE(E) - Dementia, over 65 years of age of places Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 29 Older People (OP) 4 of whom may have special mental health needs Date of last inspection 14 October 2004 Brief Description of the Service: Westerley is owned by Mutual Aid Homes, a registered charity currently trading under the name of LPMa Homes. 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. Accomodation 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 wash basins in all the rooms with seven also having 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 F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home, and took place over one day. As the manager was on sick leave on the day of the inspection, time was spent talking with the deputy manager and care staff on duty, looking at records to do with the day-to-day running of the home and the care of residents. Time was spent with some of the residents individually, and in groups and also visitors to the home. Some parts of the home were looked at. What the service does well: What has improved since the last inspection?
Decoration was ongoing with one bedroom having been completely refurbished since the last inspection. The home had also purchased new curtains and table linen for the newly decorated dining room. There was a new water feature recently installed in the front garden, which was the result of a gift to the home.
Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 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 F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 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 F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 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) 2, 3 & 5 The information given in the contract/terms and conditions was sufficient to allow the residents to make an informed choice about moving into the home. The assessments of needs allowed staff to deliver the correct level of care. EVIDENCE: All residents were given a contract and written terms and conditions when they were admitted to the home, with a copy kept on file. There was a clear admission process, which included a full assessment of needs and capabilities carried out to ensure the correct level of care was provided. Residents said that visitors could visit any time and a family member who was visiting the home on the day of the inspection confirmed this. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 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 & 10 The home’s clear and consistent care planning system, ensures residents’ health and social needs are met in a way that promoted their privacy, dignity and independence. EVIDENCE: The care plans contained information about the residents’ care needs and also an assessment of moving and handling needs. The plans were updated each month and there were details of all healthcare visits and appointments. Care plans were reviewed every six months with the resident and/or a family member taking part in the review. The care staff spoke to the residents in a polite and courteous manner and always knocked on the bedroom doors and waited to be invited in. Residents and visitors said that staff always gave personal care in a way that preserved their privacy and dignity.
Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 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 standard(s) 12, 13, &15 Regular religious services ensure all the cultural and spiritual needs are met and outings and activities provide stimulation. Residents benefit from a varied diet with vegetarian needs being met. EVIDENCE: Westerley is a Christian based home and all the residents were able to follow and enjoy their religious belief. Cultural needs were met by daily devotions and regular religious services. Activities and outings were arranged and members of the local community visit the home regularly. The majority of residents were self-caring and were able to exercise their own choice about how to spend their day. Visitors were welcome at any time and this was evidenced by the visitor’s book in the hall. The menus showed a choice at each meal and provided a well-balanced diet. A vegetarian choice was always provided. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 11 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 & 18 Residents benefit from a comprehensive complaints procedure and feel able to approach the staff to discuss matters of importance. Staff are aware of adult protection issues, which ensure a safe environment. EVIDENCE: The home had a satisfactory complaints procedure with copies on display around the home. Residents felt they were able to approach any member of staff if they felt the need. The home had an adult protection policy which included whistle blowing. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 12 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, 24 & 26 The standard of the environment was very good, providing the residents with a safe, friendly and warm environment. EVIDENCE: Since the last inspection the dining room has been re-decorated and matching curtains and table linen purchased. Arrangements were being made for new carpeting to be ordered in the near future. A new water feature for the front garden was presented to the home and was working on the day of the inspection. There were aid and adaptations throughout the building, to assist people to move about the house. The bedrooms were nicely decorated and all contained pieces of furniture and personal items brought from residents’ own homes. Domestic arrangements in the home provided clean and pleasant surroundings. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 13 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 Resident’s needs were met by staff who are experienced and trained and appointed following a rigorous recruitment procedure. EVIDENCE: There were five care staff on duty during the morning of the inspection and four on duty during the afternoon. This number did include a member of the management team. There were also domestics, a chef and kitchen assistant on duty, which ensured the residents were attended to in a prompt manner and the home was kept clean and tidy. The training programme meant that staff were able and competent to give a high standard of care at all times. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 14 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) 32, 33, 35 &38 Management practices and support provided leadership and guidance to the staff team enabling them to give a consistently high level of care. These practices ensured that the home was run in the best interest of the residents. Good financial procedures safeguarded residents’ personal finances and health and safety policies promoted residents and staff safety. EVIDENCE: Although the manager was on sick leave on the day of the inspection it was evident that she was highly motivated and gave clear leadership to the staff who spoke warmly of her help and support. The residents also expressed their appreciation of her warmth and care and all felt able to approach her at any time. Clear records concerning residents’ personal finances ensured their finances were safeguarded with monthly audits of the records conducted by
Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 15 the responsible individual. Health and safety and risk assessment procedures promote both residents and staff welfare and safety. Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 16 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 3 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 x x x 3 x 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 3 x 3 x 3 3 x 3 x x 3 Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 17 NO 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 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. 1. Refer to Standard Good Practice Recommendations Westerley F58 F10 s22667 westerley v232509 150605 ui stage 4.doc Version 1.30 Page 18 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
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