Inspection on 14/02/06 for Westfield House

This inspection was carried out on 14th February 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 found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westfield House 31/01/07

Westfield House 13/09/05

Westfield House 24/01/05

Westfield House 24/08/04

Westfield House 03/05/02

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Westfield House Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY Lead Inspector Mike Hamstead Unannounced Inspection 14th February 2006 07:00 Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 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 Westfield House DS0000003121.V281221.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 Adults 18-65. 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. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westfield House Address Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY 01709 529412 01709 529412 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) Parkcare Homes Limited Mr David Blakesley Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager show evidence of a commitment to undertake formal/training/qualification in the needs of people with mental health problems living in a residential setting One specific service user over the age of 65, named on variation dated 1 April 2005, may reside at the home. 13th September 2005 Date of last inspection Brief Description of the Service: Westfield House is part of Craegmoor Healthcare, owned by Parkcare homes Ltd and is a registered care home providing care and support for 12 adults all experiencing mental health problems between the ages of 18-65 , the youngest being 34 and the oldest 66 years of age. Westfield House cares for both male and female service users and on the day of the inspection there were 12 residents including 8 male and 4 female residents. Westfield House is located within the private complex containing two other establishments owned by Craegmoor Healthcare, Westfield Mews and Fitzwilliam Lodge. Westfield House provides accommodation that contains 11 single en suite bedrooms, and 1 training flat all completed to a high standard of specification, and the home is situated in a residential area of Rotherham and has good access to local shops and transport facilities. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, an examination of the progress made since the last inspection and the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection was commenced at 07:00 and finished at 13:30. What the service does well: What has improved since the last inspection? More staff have received training in mental health awareness issues to enable them to meet the assessed needs of residents. The activities co-ordinator has received an increased amount of money per resident towards arranging an annual holiday for them. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 6 A schedule of refurbishment, repairs and maintenance has been agreed for implementation throughout 2006, to improve the fabric, fixtures and fittings in the home. A number of residents complaints are now being recorded and being satisfactorily dealt with, reflecting a more realistic account of the problems encountered in a group living situation. 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. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3. All potential residents receive a thorough assessment of their needs, and staff are receiving appropriate specialised training in order to enable them to meet these needs. EVIDENCE: The resident group at Westfield House all have varying mental health needs, and there is one resident with an associated moderate learning difficulty. The homes assessment process enables staff to devise a plan of care to meet such needs, via staff training and supervision. A new assessment document (OBE) has been introduced and the care manager has used this to assess 2 potential new residents. Since the last inspection, and in an effort for the home to demonstrate it’s capacity to meet the assessed needs of residents, the home has commenced a programme of mental health awareness training via a visiting CPN and external trainer. This has been arranged to bolster the limited mental health content of the NVQ Level 2 qualification being studied by staff, and to date seven members of staff have completed the training and there are still four members of staff awaiting this training. This training should enable all staff attending to obtain a greater insight into some of the problems being experienced by their client group. All residents are on the Care Programme Approach (CPA), and receive Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 9 appropriate support in this respect. A 3 monthly review is held with a hospital consultant, and a (CPA) review every 6 months with a multi –disciplinary team that includes the consultant, CPN’s and social workers. The home has a training flat to encourage independent living skills, and for teaching rehabilitation and independent living skills to residents deemed to have made sufficient progress to benefit from this experience. The resident in the flat according to the care manager continues to enjoy the experience, and information from the care manager and staff indicated that he was making good progress. The care manager also stated that in his opinion there were three more residents that could benefit from a more independent living situation were this available. In addition another resident is being considered as suitable to move to the adjacent Westfield Mews, and his CPN has written to the local authority housing department stating his case, and requesting details of the housing benefits available. There was a visit from a potential resident during the inspection, who arrived accompanied by her father who said that he had looked at a number of alternative placements for his daughter but was hopeful that she could eventually be accommodated at the home, or at Westfield Mews. The religious needs of residents are respected and information is provided on their availability and location of churches/chapels for any residents that are interested. One resident continues to attend church with his parents on a weekly basis. The majority of residents have some contact with family and friends, and one resident without this facility continues to be offered advocacy services but consistently refuses the service. All staff in the home continue to act on her behalf whenever necessary, and Craegmoor act as her appointee for financial matters. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. An accurate and ongoing assessment of all residents enables their individual needs and choices to be met. Residents are consulted with and enabled to pursue their lives within a framework of risk assessment and confidentiality of information. EVIDENCE: There is a plan of care for each resident, and these were examined at random and found to be generally satisfactory. The care manager and staff are currently in the process of going through all the residents files, to archive outdated information, but have now learned that Craegmoor are introducing a new assessment and care plan documentation system from mid- march 2006, and staff have already received some training on the care planning system. All plans of care are still being reviewed via the CPA programme, on a 6 monthly basis and residents are consequently seen and reviewed by consultants on a regular basis. The inspector learned that two separate consultants had praised the care manager and staff for the work undertaken in their care of two residents, and the inspector was able to speak with one of the residents father who confirmed this view for his son. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 11 Staff continue to be aware of the need for diligence in the observation of residents, and the passing on of subtle/ significant changes in resident’s attitudes and or behaviour, which may be symptomatic of a more serious problem requiring specialised attention. This had been particularly relevant for two residents, whose changed behaviour reported by staff had led to changes in their medication, and a stabilisation in their behaviours. The needs of residents vary considerably, but staff offer assistance with, food preparation and cooking, budgeting and money management, self medication, personal hygiene, social skills and many more aspects of daily living skills to prepare the residents for the possible return to some form of supported living experience. None of the residents are restricted in visiting and contact agreed through the assessment process, and only 6 residents need assistance with managing their own finances. Residents have held their own meetings in the past, and the care manager is aware that this an area for further development, in which they are encouraged to speak freely and openly about their life at Westfield House, and to suggest any improvements that might be made. Resident inclusion has not yet extended to their participation in staff meetings, but two residents have been involved in staff selection in the past, and residents have a health and safety committee, with one of the residents being the representative to the homes management. Craegmoor organise and despatch resident satisfaction questionnaires for completion, and extend this to include relatives and friends, and this was last done on the 22nd July 2005. Staff encourage residents to get on with their lives, subject only to any risk assessment agreed at that time, and all residents are informed about the homes safety rules and procedures to safeguard their interests. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, & 17. Most residents are able to maintain appropriate and fulfilling lifestyles both in and outside the home. There are continuing opportunities for personal development and education, and community links are promoted. Regular communal and leisure activities are available, and contact with family and friends is encouraged and maintained to enable residents to engage in appropriate relationships. EVIDENCE: Lifestyle aspirations for all residents at Westfield House, varies according to a number of factors including their age, background experiences, interests and hobbies, as well as the severity of their mental illness, and their own perception of the progress being made towards recovery. All residents are encouraged to pursue their own personal development, and to become involved in activities, to maintain links with their families where possible and to lead as normal a life as is possible. Sometimes this is done in conjunction with social workers, particularly where it involves arranging day Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 13 care attendance, but more normally staff provide information and encouragement for residents to pursue any area of activity that will interest and occupy them. Two residents have become friends, that may develop, and staff are available to provide appropriate advice for any intimate relationship or seek specialist guidance as is required. The home also offers practical life skills training on a 1:1 basis to increase their self-confidence, and foster rehabilitation skills, and one resident receives 10 hours per week on a 1:1 basis, funded by the placing authority. At the present time, there is a variety and range of activities that residents are involved with including, three residents attending day centres within the week, one resident attends Eastwood Day centre 5 days per week, but told the inspector that “her wages of £10:00 per week at the day centre had been stopped”. This situation turned out to be a RMBC decision, and the care manager confirmed that the resident received an adequate income and staff would support her through this problem. Another resident goes to Clifton Court 2-3 times per week where he attends a walking group and plays snooker, and another resident attends on 2 days per week to do Maths, English and Computer studies, and another resident goes once a week for an IT course. A resident informed the inspector that she attends “Innovations” in Rotherham to do computer training. The majority of other residents do other, and just as important things that interest them, including going to the local shops and Meadowhall, helping with homes gardening, and visiting pubs and restaurants. One resident likes cycling on his own, and with a member of staff who both take their bikes and have a good day out on occasions. One resident informed the inspector that she attended an advice clinic at Swallownest hospital on how to eat healthily and avoid weight gain as a result of the medication she is taking. Generally speaking relationships with the local community are good, and residents vote at local and general elections demonstrating their community involvement. The activities co-ordinator receives a moderate activities budget but has also received an increased allowance for each resident towards a 7 day annual holiday. Since the last inspection there have been trips to York, Thoresby Hall, Christmas shopping at Meadowhall and the homes festive activities, and two residents have been to Barnsley. In addition there have been trips out for meals and drinks, swimming, and a 4 day holiday to Blackpool is being planned for the majority of residents with one resident having an alternative weekend away with staff supervision. The care manager has obtained permission to spend the holiday allowance in other ways for those residents who do not wish to have a traditional type holiday. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 14 The care manager and staff work alongside care co-ordinators and social workers to identify the possibility of employment prospects for residents, but there is nobody at present considered suitable for a job. Residents are frequently approached by the Benefits Agency on “ Back to work schemes” but any decisions made would be in conjunction with the residents social worker/CPN. The care manager is of the opinion that residents are aware that any employment may affect the benefits they receive that seems to be counter productive to their overall development into an independent living situation. All residents are encouraged by staff to become involved in independent living skills, as part of their rehabilitation process, and staff support residents in a number of ways, some mentioned above, but also provide information and encourage them to use other facilities like the library, and visit the leisure centre and other community outlets. The home also organises a weekly film night where DVD’s are available. Some residents also visit the snooker hall in Rotherham, and one resident has his own vehicle that he shares with others when involved in a joint activity. Mealtimes are flexible, but a general pattern is adhered to. Rising and retiring times are also flexible, although some routine is necessary for the residents attending a day centre. There is a “training day” for residents in the week, and staff prefer to generally encourage all residents to participate in the basic skills of cooking, cleaning and maintaining hygiene skills on an ongoing basis. The care manager has initiated a “Enhance Your Cooking Skills” event for residents, that will involve the activities co-ordinator working with residents on a 1:1 basis on a quarterly basis enabling residents to take part in buying food preparing and cooking it, with a bottle of wine thrown in. Some residents are quite adept at cooking, and others are at varying levels of learning independent living skills, requiring different levels of supervision from staff. All resident’s nutritional likes and dislikes are recorded upon admission, and currently there are four residents who are overweight, and staff try to encourage them to eat more healthily. Staff have discussed the situation with the residents and their relatives in the past, particularly where food taken outside the home or brought into the home by residents or relatives includes lots of chocolates, biscuits, or other weight gaining foods, and have suggested that this be replaced by fruit. The care manager admitted that residents had listened to this advice and the situation was not as bad as it used to be. All residents have at least one cooked meal per day, within a minimum of 3 meals per day. A risk assessment is in place for one service user prone to choking, known to all staff and the resident’s social worker. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, & 21. The home promotes the personal healthcare of all residents including specialist support required, and acts to safeguard their interests at all times. EVIDENCE: All residents receive personal and emotional support on a regular basis to a greater or lesser degree, and support with personal hygiene is identified on a “living skills” profile. One resident continues to wash her own hair and now has it blow - dried and styled by staff. Residents have some choice of staff they wish to work with them, and the home operates a key-worker system. Most residents will inform staff if they are not well in the physical sense, and staff remain vigilant in order to recognise subtle changes in residents behaviour which may be the early warning signs of something more serious approaching resulting from their mental ill – health, as mentioned earlier. The majority of residents are registered with the local GP Practice, and arrangements are in place for Chiropody Ophthalmic and Dental services. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 16 The self –harming of two residents identified at the last inspection, has virtually ceased but the care manager still has a risk assessment in place for these eventualities. Residents are now offered minimum annual health care checks that include blood pressure and cholesterol checks, and the GP practice notifies the home with a date of appointment. Two residents have been prescribed cholesterol lowering medication as a result of these checks demonstrating positive healthcare support for them. There is a medication policy and procedure, and all staff that administer medication have now received accredited training. One resident is self medicating and staff monitor this situation, and four residents visit the medication room, and administer their own medication under supervision as the first stage in an eventual process towards self-medication. The other residents have their medication administered by staff in the home. The Nomad system currently in use is being replaced by the Boots system next week, and staff have received training in the blister pack system and a refresher accredited training course is planned for all staff administering medication. This system was seen in operation and appeared to work satisfactorily, and only one resident is on a controlled drug at the present time. There is a policy and procedure to ensure that the ageing and death of a resident would be handled with dignity, sensitivity, and tact, at this distressing time. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, & 23. Staff now have a better understanding of the need to record residents complaints, and a knowledge and an understanding of Adult Protection issues that promotes the protection of residents. EVIDENCE: There is a complaints policy and procedure and a complaints record, and every resident has a copy, together with a copy of the Whistle Blowing policy. The care manager has addressed the issue of complaints at a staff meeting to ensure that all staff are vigilant in recognising and recording when actual complaints are being made by residents in order that their concerns can be dealt with. There have been four complaints recorded since the last inspection three of them coincidentally about faulty shower heads in the residents en –suites, that were all fitted at the same time, and this has been resolved. The other complaint was about the personal hygiene habits of a particular resident that has also been addressed. The home has an Adult Protection procedure, which includes a Whistle Blowing section that is posted on the office wall for all staff/service users to see, but there have been no recorded incidents since the home was registered in 2000. There is also a procedure on physical and verbal aggression by residents, and restraint guidelines are available for all staff. Training on the proper use of physical intervention and restraint techniques has not taken place since Jan/Feb 2004, and must be updated as soon as possible. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, & 30. The home requires a substantial investment, to ensure that residents live in a safe, clean, and well maintained environment. A staged programme of development has been scheduled throughout 2006. EVIDENCE: The home is suitable for its intended purpose, and comprises of 11 single ensuite bedrooms and a rehabilitation training flat, and the rooms sampled were generally satisfactory. There is also sufficient communal space via a fully furnished large lounge and conservatory, and a large kitchen and dining area to encourage independent living skills. Since the last inspection the ground floor care managers office, medication room, and computer room have been converted into an additional bedroom and alternative arrangements have resulted in the care manager being relocated in the former smoking room that was not being used. However, as a result of this action residents and staff are now smoking in the conservatory that is unacceptable, and the computer equipment is also stored in here. The inspector learned that the intention is to divide the conservatory to make a smoking room, but this is dependant upon the home having sufficient Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 19 remaining communal space after this transition, as discussed with the care manager. The entrance and corridor area adjacent to the new bedroom is scheduled to be redecorated in the next week, after which the new bedroom can be registered. In addition there are still a number of areas that need urgent attention, including the communal bathroom with an overhead shower on the first floor where the care manager is hoping to eventually have a walk in shower installed in the bathroom to improve the overall facilities. The main lounge is still in need of redecoration, and the majority of the homes corridor carpets are stained/dirty to some extent, and one staircase that is badly stained is apparently as a result of a resident’s dripping cup as he takes his drink from the kitchen to his bedroom. Staff are arranging for this resident to use a flask to prevent this situation. In addition the kitchen furniture of tables and chairs also need attention, as the tables are stained and the chairs unstable, and the inspector learned that 2 x 6 seater new tables and chairs are on order. The care manager showed the inspector a maintenance and decorating programme for the whole building for 2006, that showed that the home is to receive a staged refurbishment throughout the year, starting at the end of February 2006, and going through to the end of December 2006 that will include replacement carpets where necessary. The care manager has addressed the serious issue of 2 residents who smoke in their bedrooms, and has taken the appropriate action by writing to all residents warning them of the dangers, and also written to the resident’s social worker/CPN’s to acquaint them of the dangerous situation. Staff still monitor the situation on a regular basis, and there is no evidence that it is continuing. The care manager has also prepared a risk assessment for smoking to protect the safety of all residents and staff in the home. There is a policy and procedure on infection control, and the home was found to be free from odours on this inspection. The poor ventilation in the laundry room has been rectified and an industrial washer/dryer, with improved ventilation has been installed for the benefit of residents and staff alike. However, the residents bedroom at the other side of this wall had its en –suite door removed to improve the general ventilation, but has not had it replaced and this affects the residents privacy and dignity and must be replaced immediately. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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. There is a stable and competent staff team in sufficient numbers who receive regular updated training to meet resident’s needs, but staff supervision must be carried out at least six times per year. EVIDENCE: All staff have job descriptions, and staff are aware of their respective roles in relation to other staff including seniors, and the Care Manager. There was evidence of a good interaction between staff and residents and the home operates a key worker system. All staff receive statutory training and are undertaking NVQ Level 2 training, and at the present time and 64 of staff members have completed this. Other training undertaken since the last inspection and continuing includes fire safety training, health and safety training, infection control training, COSSH training, food hygiene training, health and health and safety training. The home provides 2 staff on duty at all times 24 hours a day 7 days a week, with 1 waking and 1 sleeping in staff at nights, and one resident is contracted for 10 hours per week of 1:1 staffing cover. In addition the home employs a part-time activities co-ordinator on 21 hours per week, a part-time domestic person on 20 hours per week over 5 days, but the administrator on 20 hours Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 21 per week is currently on maternity leave. The care manager is currently receiving administrative support from Mexborough office between the hours of 5:00 – 10:00pm at night as required. All staff were seen to be interested, motivated, and committed towards providing the best possible care for residents, and the care manager is continuing with the registered managers award, and is hoping to complete this as soon as possible. There is a recruitment and selection procedure, but there have been no staff employed since the last inspection. All staff receive a statement of their terms and conditions, and undertake a 3 monthly probationary period as mentioned in the staff handbook. All staff are aware of the homes grievance and disciplinary procedures that are kept in a copy of the staff handbook in the office. There is a staff training and development programme and plan, containing a record of individual staff’s training that is kept in the office, and all staff have an individual training and assessment profile. The home send a quarterly report of all training undertaken to Craegmoor’s training co-ordinator. All staff receive induction training, but there is to be a new format for this training as the current induction and foundation standards are being replaced by new common induction standards from September 2006. This will incorporate the former requirement to complete foundation training, and it is planned that staff will have a period of 12 weeks to complete the course. Although supervision and appraisals are taking place they are not being done to the frequency required by the standard. There are opportunities for feedback at handovers, and at proposed staff meetings, and specialised supervision is available from within the community psychiatric nursing service. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42, & 43. The care manager has considerable experience of working in a senior position caring for young adults in this client group, and is using this experience to good effect in his present role. He undertakes periodic training, and is currently undertaking the Registered Managers Award to further his expertise for the benefit of all residents. EVIDENCE: The registered care manager, has considerable experience in working with people with mental ill-health, including having worked as a deputy manager at Church View for 5 years. More recently he was the manager of the adjacent Westfield Mews for approximately 2 years, an unregistered home, providing supported living arrangements for people with a mental illness. The registered care manager came to Westfield House in April 2002 and since this date has worked hard to provide the highest standards of care for residents in the home, and continues to undertake periodic training to update his skills. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 23 The care manager has started the registered managers award and is fully aware that there is an expectation that this qualification should be achieved as soon as possible, after which there is a condition of registration that he will undertake some formal mental health training course once this has been completed. All staff confirmed that they were comfortable with the management approach of the care manager and his knowledgeable and friendly approach towards them. Staff repeated that their views were listened to, which gave them extra confidence and commitment within their role. The quality assurance system is carried out on a continuous basis throughout the year by Craegmoor, and is audited and verified by the company’s area manager. There is an annual development plan, and the home is hoping to seek Investors in People accreditation that can only be to the benefit of residents. There is a policy and procedure for the maintenance of safe working practices within the home, to provide a safe working environment for residents and staff. The fire bell is tested on a weekly basis, and the most recent fire evacuation was on the 5th January 2006. First aid training has taken place for staff, and there is a qualified first aider on duty at all times.There is a first aid box in the kitchen and the staff sleeping–in room to enable a ready access to be gained in the the interests of residents and staff. The last inspection of the gas appliances was on the 22nd September 2005, by a Corgi registered person, and the electrical hard wiring was checked on the 1st August 2005. Portable appliance testing took place on the 22nd October 2005. Renewal work on the thermostatic valves to control the water temperature has been carried out, and a test for Legionella was carried out on the 21st April 2005. The shaft lift although not used much by residents continues to be serviced, and a “Thorough Examination” was carried out on the 25th November 2005. All windows have restrictors on them, and the door is alarmed on the training flat fire door. Westfield House has a monthly budget statement for all expenditure headings, including staffing, that is monitored and controlled by the care manager, and the homes public liability insurance certificate is valid until the 4th April 2006. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 3 x x 3 3 Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 18 Requirement The registered person must ensure that staff receive updated training in the physical aggression of residents and appropriate intervention techniques. The registered person must ensure that any conversion to the conservatory takes place immediately to protect the health and safety of residents and staff. This conversion is dependent upon there being sufficient remaining communal space as mentioned in the National Minimum Standards. The registered person must ensure that residents live in a homely and comfortable environment and that the necessary redecoration is carried out. The registered person must ensure that residents live in a homely and comfortable environment with regard to the need to maintain the furniture and fittings of the building. Timescale for action 31/03/06 2. YA24 23 28/02/06 3. YA24 23 30/06/06 4. YA24 23 30/06/06 Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 26 5. YA24 23 6. YA27 23 7. YA36 18 The registered person must ensure that residents live in a homely and comfortable environment with regard to the need to maintain the cleanliness of carpeting around the home. The registered person must ensure that a replacement door is fitted immediately to a residents en-suite facility, to preserve the residents privacy and dignity. The registered person must ensure that all staff receive supervision at least 6 times per year. 30/06/06 28/02/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard YA37 Good Practice Recommendations The registered person should ensure that the Care Manager achieves a qualification at NVQ Level 4 in both management and care as soon as possible in 2006. Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Westfield House DS0000003121.V281221.R01.S.doc Version 5.1 Page 28 - 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. 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