Inspection on 06/06/06 for Westerley

This inspection was carried out on 6th June 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 12/12/05

Westerley 15/06/05

Westerley 14/10/04

Westerley 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westerley The Esplanade Grange-over-Sands Cumbria LA11 7HH Lead Inspector Mrs Margaret Drury Unannounced Inspection 09:40 6th June 2006 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 DS0000022667.V289333.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 DS0000022667.V289333.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westerley Address The Esplanade Grange-over-Sands Cumbria LA11 7HH 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) 015395 32408 The Leaders of Worship and Preachers Homes Mrs Elizabeth Lynne Davey Care Home 29 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (29) of places Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 29 service users to include: up to 29 service users in the category of OP (Older people, not falling within any other category) up to 4 service users in the category of DE(E) Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th December 2005 2. Date of last inspection Brief Description of the Service: Westerley is owned by The Leaders of Worship and Preachers Homes, a registered charity, trading under this name. It is registered to provide accommodation and care for up to 29 older people, 4 of whom may have varying forms of dementia. Mrs Elizabeth Lynn Davey is the registered manager. The home is situated near the centre of Grange-over Sands overlooking Morambe Bay. The building, which was formerly a hotel, is an older property that has been adapted and extended for its present use as a care home. Accommodation 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 the facility of shared accommodation for married couples should this be requested. There are en-suite toilets and washbasins 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 a disability to move around the home. There is a well-kept garden and a parking area at the rear of the building. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the home that took place over 1 day in June. During the inspection time was spent talking to residents, the manager, deputy manager and members of the staff team. Records pertaining to the care of residents were inspected and discussions about the general running of the home took place. The report refers to “case tracking”, a process by which the inspector is able to focus on a small number of residents and includes a review of their care documentation. It should be noted that this is not detrimental to other people living in the home. A tour of the building took place during which the physical aspects of the environment were inspected. The fees for this service range from £394.00 to £488.00 per week as at April 2006, with extra charges for newspapers and hairdressing. What the service does well: What has improved since the last inspection? A continuous programme of improvements and maintenance ensures that the accommodation is kept to safe and comfortable standards. Recent improvements have included re-decoration and refurbishment of two of the bedrooms. One of the toilets on the ground floor has been redecorated and Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 6 had new safety flooring fitted. The home has also purchased new crockery and drinking glasses. 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 DS0000022667.V289333.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 DS0000022667.V289333.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): 1, 2, 3, 4 & 5 The quality in this area is good. This judgement was made using the available evidence including a visit to the service. Admissions to the home only take place if the manager is confident staff have the skills, ability and qualifications to meet the assessed needs. Each resident is provided with a contract and terms/ conditions of residency that sets out in detail the facilities the home provides. EVIDENCE: The manager has recently completed an update of the statement of purpose and provided a copy for the inspector to examine. This document and other literature is given to any prospective and/or their families to help them to decide if the home is able to meet the needs of those looking for accommodation. Admissions to the home do not take place until a full assessment of needs has been completed. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 9 All prospective residents are invited and encouraged to visit the home prior to their admission. This gives opportunity for them to meet the staff and talk to other people living in the home. Many residents have had overnight stays or respite care and are familiar with the home and the facilities on offer. All residents are given a contract and terms and conditions of residency and there is a copy held on each resident’s file. This home does not provide intermediate care. Westerley DS0000022667.V289333.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): The quality in this area is good. This judgement was made using the available evidence including a visit to the service. Westerley provides a high standard of care, which meets the needs of the residents living there. Health care needs, including medication, are carefully monitored and residents and relatives are confident that the home can meet their needs. Care plans are of an excellent standard and ensure that each person receives the care they need to be healthy and safe, whilst promoting privacy and dignity. EVIDENCE: The deputy manager has delegated responsibility for the care planning system, which is comprehensive and extremely effective. Each resident has a care plan that is used as a working tool and is understood by all staff. It is written in clear language with resident involvement and can be used to provide information should a resident be admitted to hospital or another home, Each care plan includes a comprehensive risk assessment. Management of risk takes into account the needs of residents and demonstrates a balanced view in Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 11 maintaining safety while also offering choice. The rights of others living in the home are also considered when drawing up an assessment of risk. The care plans are updated each month and are completely reviewed with the resident every six months. All professional healthcare visits are recorded in detail and the manager and deputy manager confirmed that they have a very good working relationship with the doctors and district nurses visiting the home when required. The medication is received in a monitored dosage system and all the care staff responsible for giving out the medication have completed training in “safe handling of medication”. Records were checked and found to be in order. The home is in the process of changing the pharmacist and from the 7th of July, Boots chemist will be responsible for supplying medication. Arrangements have been made for the pharmacist to visit and complete some extra training for those staff that are responsible for dispensing the medication. Residents who spoke with the inspector said that the staff always treated them with respect and kindness and that any personal care required is given in the privacy of their own rooms. The policy for handling the death of a resident is clear, with residents’ wishes, wherever possible, recorded on the care plans. In most cases the services take place in the home. Westerley DS0000022667.V289333.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 The quality in this area is good. This judgement was made using the available evidence including a visit to the service. The routines of the home are planned around the residents’ needs and wishes and are flexible enough to meet the changing needs of the individual. Family and friends feel welcome and know they can visit the home at anytime. Maintaining independence and enabling the residents to make their own decisions about how they wish to live is a key objective for the home. An experienced cook is responsible for providing quality, nutritional meals that meet the cultural and dietary needs of the residents. EVIDENCE: Routines in the home are flexible and suit the needs of the residents. Those who spoke to the inspector were pleased that they could spend their days as they wish. Westerley is a Christian based home and all the residents are able to follow and enjoy their religious beliefs knowing that their values will be respected. Cultural needs are met by daily devotions and a newly introduced Sunday afternoon service. Other activities include a weekly aerobics class, a bible class/discussion, scrabble and completing jigsaws. Two residents sit on the Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 13 social committee and are able to make suggestions about activities and routines within the home. Although residents meetings do not take place very often the residents told the inspector that they were able to make comments to the manager and/or members of staff about the running of the home at any time. Visitors from the local churches visit the home and two residents are still able to go out in their own cars. Family members and other visitors are always made welcome with visiting times flexible enough to suit everybody. The dining room is well decorated with the tables nicely set with matching linen and crockery. Residents enjoy a varied and nutritious menu with the second choice always a vegetarian option. Special diets are also catered for. The home is situated on the front with uninterrupted views over Morcambe Bay and the residents are able to sit in the front garden in the Summer months. Westerley DS0000022667.V289333.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 quality in this area is good. This judgement was made using the available evidence including a visit to the service. The home has a complaints procedure that is up to date, clearly written and easy to understand. Residents feel confident that any issue they raise will be dealt with promptly. Training of staff in the area of protection is arranged and staff have a good knowledge of adult protection, which protects and safeguard the residents. EVIDENCE: The home has a complaints book in place but there have been none to record. The manager told the inspector that she was going to introduce a “concerns” book to record any concerns that may be raised and to show the action taken to investigate any issues raised. The home encourages open dialogue and most of the residents are well able to express their opinions. There is a copy of the complaints procedure on display in the hall. There are policies and procedures in place that outline the rights of those living in the home and these also form part of the terms and conditions of residency. All the residents who were able and wanted to, took place in the recent local elections. For those who were unable to vote in person, postal votes were organised. The manager, deputy and two senior carers recently attended a training course on adult protection and challenging behaviour and further adult protection training for all staff has been organised for the 28th of June. Staff who spoke to Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 15 the inspector showed an awareness and knowledge of abuse issues and the steps to take if action was ever necessary. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 16 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, 23, 24, 25 &26 The quality in this area is excellent. This judgement was made using the available evidence including a visit to the service. The home provides a very well maintained, comfortable and attractive home in which to live and which meets all the assessed needs of the residents. The rooms are well planned with all having en-suite toilet and/or shower facilities. There is a selection of communal areas giving the residents the choice of where to sit or meet with their visitors. EVIDENCE: Westerley is an extremely well maintained home with a good programme of repairs and maintenance. Since the last inspection two bedrooms have been refurbished to include carpets and curtains and a ground floor toilet has been decorated and the flooring has been replaced. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 17 There are two well-appointed lounges and a bright airy dining room that give ample communal space for sitting quietly with visitors, watching television or taking part in any activities. There is also a small sitting area on the first floor with spectacular views over the bay. There is a garden area at the front of the building where the residents can sit. A new awning has recently been purchased and was being used on the day of the inspection. All the bedrooms are used for single occupancy, although there are three registered as double rooms. These are not used for two people sharing unless a married couple request accommodation in the home. All of the bedrooms have en-suite toilet facilities and some have en-suite showers also. They are all well decorated and personal to the residents with pictures, ornaments and photographs. The home employs domestic staff, which ensures the home is clean and sweet smelling. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 18 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 quality in this area is good. This judgement was made using the available evidence including a visit to the service. Residents have confidence in the staff that cares for them. Staff rotas take into consideration the needs of the residents and busy times of the day. Management encourage staff to undertake training and recognise the benefits of a skilled and experienced workforce. The home has a robust recruitment and selection policy in place. EVIDENCE: The staffing arrangements in this home are very good with 4-5 members of care staff plus the manager and deputy on duty during the day and 2 waking staff at night. There are also catering and domestic staff. The staff team is both experienced and qualified with some having already completed their NVQ level 2 or above and others working towards the awards. Two members of staff are qualified trainers for moving and handling. The inspector was able to observe the staff and found their attitude to be caring, supportive and enabling. This attitude ensures that the residents can maintain as much independence for as long as possible. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 19 There is a full recruitment and selection process that ensures all the legal checks are completed prior to new staff starting work. This ensures the safety and security of the residents. There is a very low staff turnover and those living in the home benefit from knowing they are cared for by a stable staff team that they are familiar with, and have confidence in. There is a good staff training and development programme in place and staff have already completed courses in dementia, fire safety, pressure area care, medication, food hygiene, first aid, adult protection and challenging behaviour. One of the assistant managers has delegated responsibility for staff training working with the professional company Mulberry. This ensures staff training is always up to date, which benefits staff and residents. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 20 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, 36 & 38 The quality in this area is good. This judgement was made using the available evidence including a visit to the service. The manager has the required qualifications and experience and is competent to run the home. She works continuously to ensure a high quality of life for the residents. She is resident focused and leads and supports a strong staff team. The home has sound policies and procedures that are reviewed and updated on a regular basis. EVIDENCE: Discussions with the registered manager confirmed her commitment to giving the highest level of care to the residents. She works closely with the deputy manager and the staff team to ensure all the assessed needs are met. She is Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 21 well qualified, and has considerable experience in the care and support of older people. During the inspection she demonstrated clear lines of responsibility and delegation to the senior care team but also provided a “hands on approach” when necessary. Discussions with the residents and staff evidenced that she ensures the home is run in the best interest of the residents and all appreciated the fact that that could enjoy a laugh and joke with her. All staff supervision and appraisals are up to date with records held on staff files. There are procedures in place to ensure that residents’ personal finances are safeguarded even though the families are ultimately responsible for residents’ personal monies. The home has a full set of policies and procedures in place and the manager is always looking at ways to ensure these are kept completely up to date. Record keeping is of a high standard, which safeguards the residents. Health and safety measures are in place as are all fire safety procedures. One of the senior carers is responsible for health and safety, which includes all risk assessments apart from those relative to the care plans. Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 22 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 3 3 3 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 3 18 3 4 4 3 X 4 4 4 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 X 3 3 X 3 Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 23 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. 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. Refer to Standard Good Practice Recommendations Westerley DS0000022667.V289333.R01.S.doc Version 5.1 Page 24 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 © 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 DS0000022667.V289333.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!