CARE HOMES FOR OLDER PEOPLE
Westerley 1 Winton Avenue Westcliff On Sea Essex SS0 7QU Lead Inspector
Ann Davey Unannounced Inspection 12:30 2 February 2006
nd 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 DS0000015484.V271605.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 DS0000015484.V271605.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Westerley Address 1 Winton Avenue Westcliff On Sea Essex SS0 7QU 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) 01702 349209 01702 213192 westcl.ff@lpma.co.uk The Leaders of Worship and Preachers Homes Manager post vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th September 2005 Brief Description of the Service: Westerley is registered to provide care and accommodation for 24 older people. Priority admission is given to local Wesleyan preachers and their dependants, and those who share the Christian faith. The premises was converted from 2 hotels and extended in 2001 and now provides residential care accommodation. All bedrooms 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 short prayer service with hymns takes place in the lounge area each weekday morning. There is no ‘off street’ parking and the driveway provides very limited spaces. The home is situated close to the main shopping areas of Southend, Westcliff and Leigh on Sea. There are good bus and train links to the area. Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a 3.5 hour period. The inspection focused mainly on the progress the home had made since the last inspection, although some other standards were considered. A partial tour of the home took place. Staff and residents were spoken with. Records were selected at random and various elements assessed. 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 acting manager (Simon Lee) was present throughout the inspection. ‘Feedback’ was given during and at the end of the visit with opportunity for further discussion and/or clarification. The Commission is processing a registered manager’s application in respect of the current acting manager It should be noted that the email address within the ‘service information’ is incorrect. It should read ‘westcliff@lpma.demon.co.uk’, this will be corrected at the next inspection. What the service does well: What has improved since the last inspection?
Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 6 The impact of the acting manager’s management skills and abilities in the home since the last inspection was evident. It was positive and encouraging to note the improvements since the last inspection. Clearly the home took note of the requirements and recommendations made at the last inspection and many have/are being addressed. These include a review of the current lighting system in some of the communal areas, health and safety issues in the laundry area, the care planning documentation system, staff working very long days and medication administration/recording practices. The home demonstrated a positive attitude to improving standards where identified for the benefit and well being of 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 DS0000015484.V271605.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 DS0000015484.V271605.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): The above standards were not assessed at this inspection. EVIDENCE: The above standards were not assessed at this inspection. Westerley DS0000015484.V271605.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): 7,8,9 & 10 Documentation identified care, social, holistic and health care needs. Staff had a good understanding of individual needs. EVIDENCE: The care planning documentation system has been reviewed and further developed since the since inspection. Documentation selected at random was current and maintained in an orderly manner. Residents are clearly involved and participated in the planning of their daily care within the home. Residents are referred to by their preferred or chosen name. Documentation demonstrated that residents have full access to all health care agencies when required. Documentation, drug administration records and the storage of medication/drugs were in good order. The majority of residents currently accommodated fall within a minimum dependency band and only require supervision and assistance with regard to their daily physical care needs.
Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 10 Staff spoken with were knowledgeable about individual resident’s care needs. There was evidence that residents’ rights to privacy, choice, opportunity, fulfilment and dignity are upheld by the home. Westerley DS0000015484.V271605.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14 & 15 The home makes every attempt to meet individual resident’s choice, expectations and preferences on a daily basis. EVIDENCE: Residents are actively encouraged to lead a fulfilling and meaningful lifestyle within the home. Individual resident’s spiritual, social, recreational, nutritional and daily living preferences are well documented and there was evidence that whenever possible, the home facilitates and/or provides these preferences and choices. The list of social events, activities, entertainers, occupational sessions, visiting speakers, coffee mornings, seasonal celebrations and trips out is extensive and very commendable. There is an established ‘Friends of Westerley – Social Committee’. An elected resident has a place on this committee and represents the issues, wishes and expectations of other residents. Residents are consulted and participate in the forming and functioning of daily routines within the home. Residents are actively involved in menu planning. Detailed nutritional records were available. Food stocks, variety and choice of food available to residents was more that adequate. The dining area was particularly attractive in style and presentation. This aspect of care within the home was very commendable. Westerley DS0000015484.V271605.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): 16 & 18 Resident’s and visitors know how to make a complaint. Staff training is required concerning Adult Abuse Protection issues. EVIDENCE: Since the last inspection, the displayed complaints procedure has been amended and the content is now compliant with requirements. The acting manager said that since the last inspection, the home has not received any complaints. The home must ensure further POVA (Protection of Vulnerable Adults) is arranged, as senior staff spoken with were not fully conversant with the correct procedure that must be followed should an incident be reported/suspected. Westerley DS0000015484.V271605.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): 19,20,23,24,25 & 26 The environment was clean, comfortable, homely and pleasant. EVIDENCE: Resident’s bedrooms seen were very personalised and comfortable. Communal areas were homely, well decorated and furnished in a homely manner. The home was clean with no unpleasant odours. At the previous inspection, there were issues regarding the provision of adequate lighting levels in some areas of the home, insecure wardrobes and the multipurpose usage of the laundry area. It was positive to note that these matters have been/or are being addressed. Some areas of the home are quite old which makes compliance (both now and in the future) with some national minimum standards difficult. One particular identified aspect is that some radiators do not have temperature control taps/valves which allows residents to regulate the temperature in their respective bedrooms. The acting manager agreed to discuss this matter at the next residents meeting and record that the issue had been discussed (and with whom) with the agreement that if any resident had an issue, they could approach the home about it. This information should also be shared with any
Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 14 new admission. When the home’s Statement of Purpose & Service User’s Guide is next reviewed, this information should be recorded within it. On this condition (which was agreed by the inspector and the acting manager) a further ‘recommendation’ concerning this shortfall will not be made in subsequent inspection reports. It is also important that due to the style and age of some areas/facilities of the building, the home ensures that adequate risk assessments are in place at all times. Westerley DS0000015484.V271605.R01.S.doc Version 5.0 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 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, & 30 Staffing levels were adequate to meet the needs of current residents. Identified staff training needs must be developed. EVIDENCE: At the time of the inspection, the home was accommodating 14 residents. All have care needs associated with old age. None have care needs associated with dementia. Current residents have relatively low physical and mental dependency needs and therefore, current staffing levels are adequate to meet identified care needs. As more residents are hopefully admitted, staffing levels must be reviewed and increased relative to accommodated numbers and identified care needs. A current and accurate staff rota was available. It was positive to note that since the last inspection, the practice of some staff working 14 hours shifts has been phased out. It was also positive to note that arrangements are now in place for the Commission to view staff recruitment records upon request. As no staff have been recruited since the last inspection, staff records were not viewed on this occasion. Residents continue to benefit from being cared for by a stable core group of staff. Staff were observed to be caring for residents in a sensitive, respectful manner. At the last two inspections further staff training needs were identified. It was positive to note that the acting manager has now made arrangements for this to happen. A schedule/programme of training should be sent to the
Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 16 Commission and should include the names of staff that will attend, the identified course and the date the training is to take place. Westerley DS0000015484.V271605.R01.S.doc Version 5.0 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 Local management systems are established and function well for the benefit and wellbeing of current residents. EVIDENCE: The Commission is waiting for some additional documentation from the acting manager before his application for the position of registered manager can be finalised. The acting manager is due to complete his Registered Manager’s Award in June 2006 and will then go on to complete any outstanding components in order that he might also achieve the NVQ level 4 award. The home is managed and run on a daily basis in the best interests of current residents. The system whereby residents personal monies are kept and transactions recorded was sampled. Documentation was in good order and the monies held
Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 18 for safekeeping equated with the stated amounts. Residents have access to their monies at all times. The home has made good progress regarding a quality assurance process/system. It is now important that information collected is consolidated and forms the main part of a Quality Assurance/Quality Monitoring Report as required in accordance with Regulation 24. Westerley DS0000015484.V271605.R01.S.doc Version 5.0 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X X Westerley DS0000015484.V271605.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? In part only 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 OP18 Regulation 13 Requirement The registered person must ensure that all staff have received adequate training and are assessed as being competent to deal with any suspected adult abuse incident. This training must take priority. Timescale for action 31/03/06 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 OP19 Good Practice Recommendations The registered person should ensure that adequate environmental risk assessments are in place. This is with reference to the age of some aspects/areas of the premises and the limitations that this may bring about. The registered person should forward a comprehensive list of all planned staff training. The registered person should submit all outstanding documentation concerning the manager’s application. The registered person should ensure that a quality monitoring/quality assurance report is prepared and made available.
DS0000015484.V271605.R01.S.doc Version 5.0 Page 21 2 3 4 OP30 OP31 OP33 Westerley Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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