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Inspection on 02/03/06 for Westerley

Also see our care home review for Westerley for more information

This inspection was carried out on 2nd March 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It is clear that home is run to provide the best possible individual care to service users. There is an established positive group of carers. Service users are able to determine themselves how they will spend the day according to their wishes and capabilities. Some service users are able to access the nearby town independently. Others enjoy spending time in their own rooms. Service users confirmed they were well cared for at Westerley. One service user commented, "I can`t think of anywhere else that would be nicer". Another said "It is good to have someone to talk to you if you don`t feel well. They will get the doctor. We are well looked after". Service users benefit from the contributions made by all members of the support staff.Service users enjoy a wholesome and varied menu which takes into account the needs and preferences of people in the home in a very individual way. The home environment is very well maintained. It is safe, clean and comfortable. There is a choice of communal areas. The gardens surrounding the homes are particularly attractive and contribute significantly to the enjoyment and sense of well being of some service users. Service users are actively supported in the development of a variety of lifestyles and daily routines that suit them individually. There is a varied activities and social programme enjoyed by some. The home has support from the local GP practice although service users can choose to maintain their own GP. The home has amended the medication policy and adapted the method of administering medication to service users. There is continuous upgrading and decoration of the environment.

What has improved since the last inspection?

Staff recruitment files in the home have been amended to show clearly that POVA and CRB checks undertaken by Head Office were sent for and received.

What the care home could do better:

The care plans are designed to reflect the care needs and the actions to be taken whilst the service users` health is relatively stable. The home should review the plans to enable short term and fluctuating needs to be accommodated. Currently it is evident that attention is careful is paid to the service users health needs including regular visits from doctors and nurses. However this can only be seen in the daily records.

CARE HOMES FOR OLDER PEOPLE Westerley King Edward Road Minehead Somerset TA24 5JB Lead Inspector Shelagh Laver Unannounced Inspection 10:30 2 March 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 DS0000016017.V283636.R01.S.doc Version 5.1 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 DS0000016017.V283636.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westerley Address King Edward Road Minehead Somerset TA24 5JB 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) 01643 702066 01643 708978 The Leaders of Worship and Preachers Homes Mr Vaughan Clive Ogden Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: Westerley is a large detached property, set in spacious and beautifully maintained gardens. The home is situated close to the centre of Minehead, where there are all local amenities. The home is registered with the Commission for Social Care Inspection to provide care and accommodation for up to twenty-three people over the age of 65 years, who require assistance with personal care. The Registered Manager is Mr Vaughan Ogden. The Registered Provider is Mutual Aid Homes trading as LPMA Homes. The Westerley aims to provide care to service users within a Christian community. A short Christian service takes place in the home each morning. Service user accommodation is provided over two floors. There is a passenger lift, two assisted bathrooms and a call system available to service users. All areas of the home have been well maintained and furnished to a high standard. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on one day over four hours and was conducted by one inspector. On the day of the inspection there were sixteen service users living in the home. The home has widened its service users group and is now admitting service users who have been leaders of worship in a range of Christian denominations who are assessed as needing residential care. A tour of the premises took place where a selection of bedrooms and all communal areas were seen. Eight service users were spoken with individually. The registered manager Mr Ogden and Deputy Manager Mrs Ogden were on duty in the afternoon and were able to assist the inspector. Records relating to care, staff and health and safety were examined. Plans to provide three new bedrooms are nearing completion. These ground floor rooms were seen by the inspector and are attractive and comfortable. What the service does well: It is clear that home is run to provide the best possible individual care to service users. There is an established positive group of carers. Service users are able to determine themselves how they will spend the day according to their wishes and capabilities. Some service users are able to access the nearby town independently. Others enjoy spending time in their own rooms. Service users confirmed they were well cared for at Westerley. One service user commented, “I can’t think of anywhere else that would be nicer”. Another said “It is good to have someone to talk to you if you don’t feel well. They will get the doctor. We are well looked after”. Service users benefit from the contributions made by all members of the support staff. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 6 Service users enjoy a wholesome and varied menu which takes into account the needs and preferences of people in the home in a very individual way. The home environment is very well maintained. It is safe, clean and comfortable. There is a choice of communal areas. The gardens surrounding the homes are particularly attractive and contribute significantly to the enjoyment and sense of well being of some service users. Service users are actively supported in the development of a variety of lifestyles and daily routines that suit them individually. There is a varied activities and social programme enjoyed by some. The home has support from the local GP practice although service users can choose to maintain their own GP. The home has amended the medication policy and adapted the method of administering medication to service users. There is continuous upgrading and decoration of the environment. What has improved since the last inspection? 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 DS0000016017.V283636.R01.S.doc Version 5.1 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 DS0000016017.V283636.R01.S.doc Version 5.1 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. The manager ensures that the home can fully meet the assessed needs of prospective service users prior to making a decision about admission. The pre-admission process is detailed and well managed. The manager ensures that prospective service users are provided with appropriate information which will assist them in making a decision about admission. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide which is made available to service users, prospective service users and their representatives. The home’s current fee range is dependant upon the room to be occupied and the assessed needs of the service user. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 9 The manager ensures that prospective service users are fully assessed prior to admission. The manager ensures that a service user is visited if possible and information from other health professionals and for example hospital care notes are taken into account. Service users are invited to visit the home whenever this is possible. The manager liaises with other home managers in the group if the service user lives too far away to be visited. The manager nearest the service user will undertake the assessment and provide information. Documentation relating to pre-admission assessments was seen in the two care plans examined. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 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. The home takes appropriate action to ensure the health care needs of service users are met. The home’s procedure for the management and administration of medication was found to be satisfactory. Service users are treated with respect. Care practices support privacy and dignity. EVIDENCE: All service users have care plans maintained. Two were examined and were found to be up to date and well maintained. There were monthly reviews. Care plans are compiled from appropriate assessments, which include preadmission assessment, prevention of pressure sores, moving and handling needs and nutrition. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 11 It was observed from care plans that service users have access to appropriate health care professionals. District nurses and GPs are currently visiting regularly. One care plan examined demonstrated that the home ensured service users accessed the service of specialist nurses and consultant clinics. The care plans are designed to reflect the care needs and the actions to be taken whilst the service users’ health is relatively stable. The home should review the plans to enable short term and fluctuating needs to be accommodated and easily followed. Currently it is evident that attention is careful is paid to the service users health needs including arranging urgent visits and treatment from doctors and nurses. However this can only be seen in the daily records which must be read thoroughly to gain a full picture of a service users medical status. All staff attended to and addressed service users with respect and in a dignified manner. All service users asked confirmed that they are well cared and treated with respect Westerley. Service users received visits from chiropodists and opticians. Some maintain links with services in the community. There was evidence from conversations with service users and in the care plans that service users had gained in health and independence since coming to Westerley. The home uses the Monitored Dosage System (MDS) with some additional boxed prescriptions and pre-printed MAR charts. All records examined were appropriately completed. Medicines were seen to be appropriately stored. Guidance has been provided to the home in relation to insulin provided for one service user. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 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. Service users are able to choose a variety of lifestyle patterns in the home. The home provides a wholesome and varied menu which takes into account the needs and preferences of service users. Arrangements for service users to maintain contact with family and friends is good. The home provides activities and entertainments to enrich the service users lives. EVIDENCE: The home menu is wholesome, appetising and varied and takes in to account the needs and preferences of service users. Service users are informed in the morning of the choices available for lunch. Service users confirmed that there was always something “different” available. A service user said, “We are never allowed to be hungry”. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 13 There is a cooked breakfast choice each day. The dining room is pleasant and tables are set to a good standard. Visitors are made welcome at any reasonable time in accordance with the wishes of the service user. There is a choice of communal areas ensuring there is always “a quiet spot”. Some service users prefer to meet visitors in their rooms that were seen to contain sufficient seating. Service users are encouraged to maintain their interests and hobbies wherever possible. ‘Devotions’ take place in the lounge each morning. Service users at the home are able to participate in a range of activities including exercises and after tea events. There is a small library. Visitors are welcomed at the home. Local clergy also make visits to the home on a regular basis. Service users are able to bring possessions with them into the home. All service user rooms had been individualised with photographs and personal belongings. Service users were smartly dressed and have the regular services of a hairdresser. There is an efficient laundry service that included hand ironing. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 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, 17 & 18. The complaints procedure in this home is good with evidence that the views of service users/visitors are listened to and acted upon. Procedures and policies aim to protect service users from abuse. EVIDENCE: There had been no formal complaints. Service users spoken to knew whom they were able to speak to if they wished to complain. One stated that the manager “would soon sort things out”. Staff recruitment procedures, training and supervision contribute to the protection of service users from abuse. Records of service users’ finances were observed to be detailed accurately at the last inspection. Service users who are able are encouraged to be independent and mobile. They are protected by policies and procedures in the home. In the staff room guidance on preventing and recognising elder abuse was displayed. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 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, 20, 21, 22, 23, 24, 25 & 26. Service users live in a comfortable, safe and clean environment and are able to personalise their own bedrooms. The home’s environment is able to meet the assessed needs of service users. The home provides specialist equipment to ensure the needs of service users are met. EVIDENCE: All communal areas and most bedrooms were seen at this inspection. Bedrooms were pleasant and comfortable and it was evident that service users were encouraged to bring personal possessions into their rooms. Specialist beds and pressure relieving equipment were seen to be in place where there was an assessed need. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 16 Service users informed the inspectors that they were very satisfied with their rooms. Some appreciated the views from the bedroom windows across the gardens. There is a choice of sitting areas and the standard of decoration and furnishing is comfortable and smart. The home has a lounge, a dining room and a conservatory. Bedrooms are decorated systematically and service users choose colours and patterns of rooms. The home showed evidence of steady investment. Service users have a choice of where to spend the day. Some prefer to spend a great deal of their time in their bedroom although all are encouraged to come to the dining room for lunch if they are well. Overall the home is very pleasantly decorated and well maintained. The standard of cleanliness was very good. Carpets are deep cleaned regularly and replaced on a rota. Domestic staff on duty were satisfied with the time provided to care for the home and the equipment provided. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 17 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. The home ensures that there are sufficient staff on duty to meet the service users needs. The home’s recruitment practices are robust and designed to protect the service users. Staff are well trained and have access to a range of mandatory and developmental training opportunities. EVIDENCE: On the day of inspection there were three care staff on duty. Also on duty were the cook, two domestic staff and the gardener. The duty rota showed permanent staff working in numbers to meet the needs of service users. The manager discussed some problems recruiting staff but this is being managed. The home’s training and development plan was seen by the inspector and discussed with the manager. Staff spoken to confirmed they had received manual handling up-dates and fire training. Written records of training were seen. 64 of staff have NVQ2 and above. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 18 Two new staff files were observed and demonstrated sound recruitment practice. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 19 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, 34, 35, 36, 37 & 38. The home is effectively managed by the registered manager who promotes a clear and inclusive style of management. Measures are taken which ensure the needs and well being of service users takes priority and that staff are appropriately supported and supervised. The home’s systems for ensuring the health, safety and welfare of service users and staff are structured and well managed. EVIDENCE: Mr and Mrs Ogden demonstrated through discussion with the inspector that they had a very clear understanding of the needs of service users living at the Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 20 home. They are clearly committed to meeting the needs of the service users and to the effective running of the home. Staff benefit from regular meetings. Staff have annual appraisals and supervision sheets are completed. The manager is an experienced administrator responsible for managing the finances of the home, maintaining appropriate records and liaising with Head Office. At the time of this inspection, the home was taking appropriate steps to ensure the health & safety of service users, staff and visitors to the home. The following records were examined: FIRE – Records indicated that appropriate checks were being carried out on the home’s fire detection and fire fighting equipment. Regular training is conducted for all staff. SERVICING – Servicing schedules indicated that hoists are serviced according to LOLER. There are planned dates for all servicing. ACCIDENT – The home maintains appropriate records relating to accidents at the home. The accident records include action to be taken and evidence of analysis. HOT WATER/SURFACES – Bath hot water outlets are thermostatically controlled to reduce the risk of scalding. Those checked at this inspection were found to be within the acceptable limits. First aid training is provided for staff. Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 21 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 3 3 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 22 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. 1. Standard OP7 Regulation 15 (2) Requirement The manager must review the format of the care plans to enable short term and fluctuating care needs to be easily followed. It is important that actions to be taken with regard to these needs and visits by medical professionals can seen quickly by staff. Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westerley DS0000016017.V283636.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 DS0000016017.V283636.R01.S.doc Version 5.1 Page 24 - 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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