Inspection on 31/01/07 for Westfield House

This inspection was carried out on 31st January 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westfield House 14/02/06

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 Ivan Barker Key Unannounced Inspection 31st January 2007 10:15 Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 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.V327172.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V327172.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield House Address Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY 01709 529412 01709 529412 none info@craegmoor.co.uk Parkcare Homes Limited 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) Vacant Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 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 1. One specific service user over the age of 65, named on variation dated 1 April 2005, may reside at the home. 14th February 2006 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 13 adults all experiencing mental health problems between the ages of 18-65. Westfield House cares for both male and female service users and on the day of the inspection there were 12 residents. Westfield House is located within the private complex containing two other establishments owned by Craegmoor Healthcare, Westfield Mews and Fitzwilliam Lodge. Westfield House is a converted building providing accommodation that consists of 12 single en suite bedrooms, and 1 ‘training’ flat. There is a non-operational lift within the facility. However the service users are all ambulant. The home is situated in a residential area of Rotherham and has good access to local shops and transport facilities. Copies of Statement of Purpose and Service User guides were available to service users and stored in their rooms. The manager advised the inspector that the fee range is between £431.81 and £601.88 Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Mrs D Wilkins, manager. Within this inspection, which occurred over a three hour forty-five minute period, the inspector toured the building, examined requirements relating to the previous inspection, spoke with 2 service users, and 2 staff and examined assessment, care plans, activity records documentation and staff files. What the service does well: What has improved since the last inspection? At the previous inspection there was a shortfall regarding training. The staff had received Safeguarding Adults training and supervision. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 6 Throughout the past year the home has acted upon a programme of improvement within the decoration and refurbishing of the home. The corridor area had been redecorated, and new carpets provided. 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. The summary of this inspection report can be made available in other formats on request. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 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.V327172.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate comprehensive assessments were in place that ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: There was evidence that the service received care assessments from the care management team or the hospital prior to admission. The acting manager or deputy visited the service user and undertook an assessment prior to admission. Documentation of the service users who were being case tracked was examined and found them to be comprehensive, and detailed the service users needs which would assist in providing sufficient information for a care plan to be drawn up. Each assessment, which identified the service user’s needs were converted into a specific contract for that individual, within a fee banding range of £431.81 and £601.88. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate care plans and care reviews with service users and relatives enable them to offer their input and so contribute to the delivery of care. EVIDENCE: On examination of the care plans of the service users who were case tracked, the care plan documentation was extensive and contained a considerable amount of information, but was difficult to reference the prescription of care that staff would need to follow to deliver care. The deputy manager showed the inspector copies of the ‘old style’ care plans, which clearly indicated prescriptions of care and were easier to follow. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 10 It was agreed that the use of both documents could be beneficial, as they would complement each other. Thereby providing extensive information with a ‘user friendly’ instructional prescription of care. The care plans had a daily entry, which was dated and signed. The plans were evaluated and reviewed on a monthly basis. Risk assessment were included within the documentation and included moving and handling, pressure area risk assessments etc. Discussions with service users identified that they were satisfied with the care, which was provided. Two service users had their personal monies held for security by the home. The money was held within metals tins stored in a safe. An accounting system for these monies was in place and showed debts and credits. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service was unable to evidence that various activities and outings were organised within the home, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. EVIDENCE: No service users attended college or other educational facilities, however 2 service users attended day centres. There was evidence in the care plans that service users visited shops, pubs and other local amenities. Also friends and family visited the service. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 12 On discussing the availability of activity and therapy sessions, it was noted that the activities co-ordinator was leaving ‘this week’ and that an advertisement had been placed, and applications had been sent out. A date for interviews was yet to be set. On examination of the activities daily record, these were found to be minimal, with many omissions over several days and months. It was agreed with the acting manager that the records were poor. Some service users had their own keys to their rooms. Many service users chose to lock their door, whilst in the room. Staff were observed to knock on the door, and then waited until they were invited into the service user’s room. A master key was available in case of emergencies. Regarding meals there was evidence on menu sheets that a choice of meal was available. The acting manager advised the inspector that meals were discussed at service users meetings. Service users expressed their satisfaction at the meals, which were served. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The good practices within storage and administration of medications should provide protection for the service users. EVIDENCE: The service users were able to maintain their own independence as able, but received support from staff as detailed in the care plans. On examination of the care plans it was established that service users were able to access community services which included GP, dentist etc. The medication room was a small room, which had an air-conditioning unit fitted to the wall for the purpose of maintaining the medication at a satisfactory temperature. The medication was the Boots medication system. The ordering, administration and disposal procedures were discussed with the acting manager. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 14 The procedures explained were satisfactory. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. There was an initial and signature sheet, within the medication administration file. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service had a complaints procedure in place, however there was no available evidence to judge if it was operating according to the company policy and if complaints were resolved within the expected timescales. The service was able to evidence that the staff had received Safeguarding Adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: Complaints procedures were displayed at the entrance to the service. The manager identified that there were no complaints. No complaints were expressed during the visit. Regarding Adult Protection, Procedures were available within the office and available to all staff. On examination of the staff training record it was established that the record indicated that all staff had attended Adult Protection Training. Regarding the previous requirement from the last inspection, regarding the need for training in learning intervention techniques in the case of physical aggression. This had been addressed. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The environment, monitored at this inspection, had not been maintained to the required standard to provide a safe, well-maintained environment for services users. EVIDENCE: On touring the building, the service was found to be generally clean and adequately decorated and in a reasonable state of repair except for the following areas: Within Room 8, the hot water temperature was found to be in excess of 43 degrees centigrade. The manager agreed that the temperature was above 43 degrees centigrade but expressed her surprise at this fact as the ‘handyman’ monitored the temperatures on a regular basis. It was accepted that the temperature was not hot enough to scald and cause injury, but the manager Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 17 advised that she would raise the issue with the handyman and all hot water outlets available to service users would be rechecked. Within Room 5 the shower attachment was broken and needs to be repaired. An en-suite facility identified to the manager was dirty and had accumulated dirt on the floor. On discussing this matter with the acting manager, it was noted that the service user allows care staff into the room, but not cleaning staff. Following further discussions it was agreed that cleaning needed to occur to ensure adequate hygiene and cleansing and to control any cross infection. The manager agreed to have discussion with the service user and establish a way of cleaning the en-suite. Within Room 1 the en suite floor covering was excessively stained and had mould to the corners and base of the tiles. The manager advised that a new floor was being fitted, however no timescale was given. The rooms had been personalised and were of a style that demonstrated that ‘younger adults’ resided within some of the rooms as these contained posters and picture that would appeal to a younger group. Some of these rooms were untidy, but it was accepted that it was the service user’s choice to live in such an environment. Again the importance of maintaining service user rights and choice with hygiene and safety was discussed. Within the conservatory, all the plastic roof trusses were stained with dirt and in need of extensive cleaning. The plastic glazing was also dirty, as was the horizontal blinds. The acting manager advised that in view of the age and condition of the conservatory it was planned to be demolished, and replaced by a new conservatory. She also identified that quotations had been obtained with a timescale of 6 months for completion. The timescale was accepted. The Commission will need to be kept informed of the commencement of the work and expected period the work will take, and what strategies are to be put in place to provide sufficient communal space (lounge space) during this period. Regarding the previous requirement regarding the conservatory and the smoking issue has been acted upon and resolved. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager was able to provide evidence that staff had received training, which should reflect on the quality of care being delivered to the service users and the staff recruitment process should provide protection for the service users. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the inspector established the following: Am – Pm – Night shift – Plus The deputy manager who was sometimes included in the 2 care staff number. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 19 2 care staff 2 care staff 1 care staff on duty and 1 waking staff. The activities co-ordinator employed for 21 hours per week The administrator employed 20 hours per week, over 5 days. 1 domestic person per shift. Caring for a present occupancy of 12 service users. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. On examination of the two staff files, both contained the required documentation, including Criminal Records Bureau and POVA checks. On examination of the staff training records there were records and certificates that indicated all staff had received moving and handling, fire, adult protection training and other specific training regarding the client group that they were caring for. Staff advised that they were satisfied with the care and service provision and did not express any concerns. Regarding the previous requirement of the lack of staff supervision, this has now been acted upon and staff received supervision on a regular basis. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A manager has been appointed and to comply with The Care Homes Act, needs to submit an application and undertake the registration process. Extensive quality assurance systems were in place that should assist the manager and company to measure the home against expected outcomes. EVIDENCE: A manager had been appointed to the service. Her position had been discussed with the CSCI (Commission for Social Care Inspection) She identified that she is to submit an application for registration to become the registered manager. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 21 Regarding her qualifications and experience she identified that she had more than the two years experience and had obtained the Registered Managers Award. Regarding the Quality Assurance there was regular monitoring with the last audit being January 2007. At this audit, undertaken by the administrator the home achieved 90 of the internal audit standards indicated on the audit tool. The value of the audit tool when 90 was being obtained with the option of either being more critical with the analysis or providing a higher standard document to be measure against was discussed. Regulation 26 documentations, which are a record of the registered persons monthly visits, had been completed on a monthly basis and were on site for inspection. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, had been received by CSCI. The pre inspection questionnaire confirmed that the necessary maintenance and servicing had occurred. Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 22 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 X 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 23 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 2 3 Standard YA12 YA24 YA37 Regulation 16 (2) (n) 23 (2) 8 Requirement There must be more recreational facilities provided and evidenced by the service The service must be adequately cleaned within the areas of the en suites and the conservatory. The appointed manager must submit a registration application to the CSCI and undertake the registration process. Timescale for action 03/03/07 03/03/07 23/05/07 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 Westfield House DS0000003121.V327172.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V327172.R01.S.doc Version 5.2 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. 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