Inspection on 17/08/06 for Westerley

This inspection was carried out on 17th August 2006.

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 18/01/06

Westerley 18/03/05

Westerley 26/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westerley Broadway Woodhall Spa Lincs LN10 6SQ Lead Inspector Kima Sutherland-Dee Unannounced Inspection 17th August 2006 09:30 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 DS0000002473.V308329.R01.S.doc Version 5.2 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 DS0000002473.V308329.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westerley Address Broadway Woodhall Spa Lincs LN10 6SQ 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) 01526 352231 Methodist Local Preachers Mutual Aid Association. Jayne Margaret Tewnion Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Westerley is situated in the spa town of Woodhall Spa and in close proximity to local shops, churches, chapels, park, kinema and other community amenities. The building is a 2-storey detached complex, which has been extensively refurbished. The environment, both internally and externally, is maintained to a high standard. All rooms used by service users have en-suite facilities. The home is run by the Mutual Aid Homes, which trades as LPMA Homes. The parent organisation, the Methodist Local Preachers Mutual Aid Association (LPMA) is a Christian charity set up specifically for Methodist Local Preachers and their dependents. However, their homes now accept applications from Lay Preachers and service users from other denominations. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information provided by the manager relating to Westerley and by visiting the home. The inspection was unannounced and took place over 3hrs 40mins. The inspector used case tracking as a method of inspection, which involved selecting two residents currently living at the home and tracking their experience of care and support, examining their records and listening to their views. The inspector toured parts of the building, looked at a range of records and spoke with the assistant manager, two members of staff, and seven residents, as well as observing day-to-day practice within the home. The fees for this service range from £394 to £495 depending on the needs of the residents. What the service does well: What has improved since the last inspection? What they could do better: Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 6 The recently registered manager has begun to re- introduce staff meetings and supervision, however these need to be prioritised. The staff said they do get informal support and they discuss care at each shift handover, but they must also have the opportunity to formally discuss their roles and this must be recorded. This is necessary because the staff need to have individual sessions so that the manager and staff can discuss their work standards. The staff need to ensure that they include enough details on the daily records about the care they give to the residents. This will then allow the staff and managers to monitor the residents improving or deteriorating health, as wells as whether the staff are delivering the necessary care. 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 DS0000002473.V308329.R01.S.doc Version 5.2 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 DS0000002473.V308329.R01.S.doc Version 5.2 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): 2,3,4,6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager does provide the information that new residents need before and during their admission. EVIDENCE: Two contracts including terms and conditions were seen. The residents had signed them. The assistant manager explained the admissions process and said that the managers would remind the residents about their terms and conditions and the services the home provides over the first few days after their admission. New residents are sent a letter before admission that confirms their place and they are also sent relevant policies and information about the home. Service users are assessed prior to admission, through chatting to them, their relatives and gathering any other information that is available. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 9 This home does not provide any intermediate care, although they can provide respite care. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The resident’s health and personal care needs are being met. The staff are treating the residents with dignity, whilst maintaining their privacy. EVIDENCE: The senior staff use the initial assessment to develop a brief care plan and personal details sheet. This is then expanded, after about a month when the staff have got to know the resident. There is evidence that the care plans had been reviewed. Some of the contact sheets were very brief. The lack of more detailed records in the daily sheets did not put residents directly at risk, however they failed to adequately monitor the residents progress or deteriorating health. The staff were able to give detailed examples of the care that a resident needed and how this was carried out. The staff were aware of the health needs of each resident. Medical appointments and treatment were recorded and the District Nurses were involved in the care. The care plans do indicate what emotional support the residents need, and any treatment they are receiving. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 11 A new medication trolley system is now in use, the staff and the assistant manager said this is working smoothly and that the residents have noticed the change. Staff were observed knocking on the residents doors before entering, they were also seen offering sensitive care and demonstrating their commitment to offering a high standard of care. The residents commented that ‘ The staff are wonderful and very kind’ ‘ this is the best home and the staff are always lovely’. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The residents experience a lifestyle at this home that they say suits their expectations and preferences. EVIDENCE: The residents said they were very satisfied with the lifestyle at the home, they were able to maintain their own interests and the staff encouraged them to maintain their independence. This was confirmed by the comment cards that the residents completed and returned to the commission. The staff spoke about their knowledge of individuals and how they help them. Eight residents were sitting in the conservatory chatting, 3 of them had a game of scrabble. The notice board advertises activities and trips, along with church services. Staff said they try to take residents out individually, and one person had gone to the village during the inspection. The residents are involved in the local community through access to facilities and the local church’s. The residents said that their relatives are welcome at any time. A friend telephoned for a resident who chose not to arrange a visit that day, this demonstrates that they are able to choose who they see and when. Previous inspections and information sent to the commission by the residents indicate that the residents are very satisfied with the food provided at the Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 13 home. The inspector spoke to the cook who had a detailed understanding of each resident’s preferences and nutritional needs. The dining room offers a relaxing and comfortable area for meal times. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 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 the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The residents are protected from abuse and the staff are confident to deal with any concerns or complaints. EVIDENCE: One member of staff said they received abuse awareness training in April as part of the dementia course. The staff also said there was information about how to deal with suspicions of abuse on the staff notice board. They would report any complaints or concerns to senior staff or the managers and that they felt the managers were very approachable. Two residents said they know how to complain and 12 of the 14 comment cards confirmed this. The assistant manager said that no new complaints had been raised, but that when some of the residents raise issues informally, they are reassured and the matter dealt with. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 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 the following standard(s): 19,24,26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is well maintained and comfortable, it meets the needs of the current residents. EVIDENCE: The home is clean, odour free and well maintained. Three residents said they like their rooms and that they were comfortable. Three bedrooms were seen and they were comfortably furnished and they contained many personal possessions. The home is fully accessible for all abilities, and this includes the outdoor spaces and gardens. Thirteen of the Fourteen comment cards said that the home was clean and comfortable. One said that the home was ‘immaculate and always fresh and clean’. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 16 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The staff are competent and they meet the resident’s needs. EVIDENCE: One staff member was interviewed and they said that they felt very well supported by the managers, even though they haven’t had regular staff meetings or formal supervision. Staff said they share information about the residents at handover, between each shift and by looking at the care plans when they find time to do this. One of the comment cards stated that the staff were rushed and busy and more staff were needed. The other comment cards were complementary about the care. The staff said that there are enough staff to care for people and they try not to rush even when they are very busy in the mornings. The also said they have more time mid morning to take people out or to spend time chatting to the residents. Two staff files were seen they did contain the recruitment records, but they did not contain up to date supervisions past 2004 or inductions to the home. One member of staff said that they really enjoyed working at the home and the staff team worked very well and supportively together. Staff training is offered and the Pre inspection questionnaire states that recent courses have included, dementia care, lifting and handling and first aid. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is competently managed. There are no formal staff supervision sessions. EVIDENCE: The recently registered manager was on holiday at the time of the inspection. The residents have opportunities to air their views, they say that the manager is very approachable and a visitor who carries out monthly audits and sends the results to the commission asks them about their care. Fourteen residents returned comment cards to the commission and apart from one they were extremely positive and satisfied with the service at the home. One resident said they were dissatisfied but they have not raised this with the assistant manager. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 18 The assistant manager stated that a visitor from head office visited the home last month and spoke to the residents and the staff. The chairman of the trustees report was available to the residents on the notice board. The assistant manager confirmed that the last staff meeting was in April and that the previous managers had not held supervisions with staff for about a year before their retirement because they had not wanted to commit to training, which they could not supply. The new manager is beginning to implement staff supervisions and has held one staff meeting since April. However the staff do not have a formal way of discussing their role or being informed about policies or standards to work to. The manager needs to see the implementation of supervisions as a priority so that staff can have clear direction. The Pre inspection questionnaire states the dates when equipment and safety checks were carried out, and the environment is safely maintained. The care plans include individual risk assessments. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 20 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. 1 Refer to Standard OP36 Good Practice Recommendations The registered manager must ensure that the staff receive appropriate supervision and that this is recorded. Westerley DS0000002473.V308329.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 DS0000002473.V308329.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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