Inspection on 15/01/08 for Westfield Mews

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Good service.

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 Mews 31/01/07

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 Mews Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY Lead Inspector Michael O`Neil Unannounced Inspection 15th January 2008 09:20 Westfield Mews DS0000067775.V355716.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 Mews DS0000067775.V355716.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 Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westfield Mews Address Westfield Road Rawmarsh Rotherham South Yorkshire S62 6EY 01709 524436 F/P01709 524436 westfield.mews@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd 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) Post Vacant Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2007 Brief Description of the Service: Westfield Mews is part of Craegmoor Healthcare, owned by Parkcare homes Ltd and is a registered care home providing care and support for 9 adults all experiencing mental health problems between the ages of 18-65. Westfield Mews cares for both male and female service users. Westfield mews is located within the private complex containing two other establishments owned by Craegmoor Healthcare, Westfield House and Fitzwilliam Lodge. Westfield Mews is a converted building providing accommodation that consists of 9 single en suite bedrooms, with a kitchenette / lounge area. 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 people and displayed in the foyer of the home. The manager advised the inspector that the fee range is between £600 and £1058. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Mike O’ Neil, regulation inspector. This site visit took place between the hours of 9:20 am and 3.00pm. Dawn Wilkins is the manager and was present during the visit. Dawn has submitted an application to the CSCI to become the registered manager. She is already the registered manager for Westfield House, the service on the same site as Westfield Mews. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to four staff and five people. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in January 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home and the staff for their time, friendliness and co-operation throughout the inspection process. What the service does well: People said they could make choices in their life whilst staying at Westfield Mews. People made comments such as “staff support me to get on with my life” and “staff give me the level of help I need on that day”. People were supported to maintain family links and had the opportunity to meet people and make friends. People were very positive about the level of care and support they received at Westfield Mews and made comments such as “Staff are brilliant here” Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 6 “Staff are really helpful and kind” “There is a really nice atmosphere at Westfield and we all get on” People said if they had any concerns they would feel very comfortable in speaking to the manager about them. The home was bright, clean and welcoming. It had homely touches in the shared rooms and people had personalised bedrooms. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. A good training and induction programme was in place for staff. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westfield Mews DS0000067775.V355716.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 Mews DS0000067775.V355716.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were individually assessed prior to admission to ensure their needs could and would be met. EVIDENCE: Care plans showed that people within the service had been assessed before moving into the home. Risk assessments and a detailed plan of care reflected any specialist interventions. The manager and staff liaised with professionals and families to find out about peoples needs. The manager or deputy visited the person and undertook an assessment, prior to admission. Westfield Mews DS0000067775.V355716.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provided staff with sufficient information to meet the needs of people who use the service. People were assisted and supported by staff to make decisions and choices about all daily living needs. EVIDENCE: Three peoples plans of care were seen. These contained information on aspects of personal, social and health care needs. The plans contained some good profile information, including records of medical /mental health support and risk assessments for all aspects of peoples day-to-day lives and behaviours. People said they were aware of what was in the care plans and said they participated in regular reviews with staff and visiting health professionals. The persons care plans and assessments contained good detail but some of the information was repeated making the document very bulky and difficult to Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 10 track a persons plan of care .The daily records were also kept in a separate file from the care plan. This practice could lead to difficulties and the risk of support workers writing daily records in isolation of a persons care plan. The manager said she was in the process of reviewing people’s care plans in line with the organisations new care-plan format. The new format is more person centred in its approach and planning. People said they could make choices in their life whilst staying at Westfield Mews. For example people said they shopped for themselves with or without support, chose what they wanted to do during the day and whom they preferred to spend time with. People were supported in taking risks as part of their daily living to enable them to be as independent as possible. People made comments such as “staff support me to get on with my life” and “staff give me the level of help I need on that day”. Westfield Mews DS0000067775.V355716.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The service provided, promoted and encouraged development of social and practical skills. This ensured that people had the opportunity to participate in leisure activities and live as part of the community. In the main people were given the opportunity to exercise their right of choice regarding their daily lives. EVIDENCE: People had the opportunities to develop practical life skills and social skills and make the most of their abilities. Daily routines within the home were flexible and individual, for each person who uses the service. Activities were arranged for each individual. Group activities were also available. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 12 People said they go to college or day centres on weekly basis. There was evidence in the care plans that people visited shops, pubs and other local amenities. People were supported to maintain family links and had the opportunity to meet people and make friends. Some people said they had been on holiday and were looking forward to going away again this year. People had their own keys to their rooms/flats. Staff were observed to knock on the door, and then waited until they were invited into the persons room. People were given the opportunity to exercise their right of choice regarding the provision of meals and were supported by staff to eat as healthily as possible. Two people did express concern however that they had no choice in relation as to where they received their medication when staff dispensed it. People said they had to walk outside to the office at times in the dark and wet weather, which was not nice. One suggestion from people and the staff would be to site a new door in the communal lounge. This would enable internal access to the office and medication storage room. People said there were more opportunities for recreation since the last inspection. Documentary evidence was available to support people’s comments. Westfield Mews DS0000067775.V355716.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People’s health is monitored and arrangements for dealing with health issues were met with support from health professionals. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Care plans showed that people’s health was monitored and staff had access to health care facilities and any relevant specialists that were necessary. Records clearly showed that people were assisted and supported by staff to make decisions and choices about all daily living needs. Detailed information of peoples personal care needs was recorded, this also included people’s wishes and preferences, or when staff provided personal support in daily routines. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 14 Risk assessments were in place to identify any risks and how they can be managed. People were very positive about the level of care and support they received at Westfield Mews and made comments such as “Staff are brilliant here” “Staff are really helpful and kind” “There is a really nice atmosphere at Westfield and we all get on” Medication checked at the site visit was stored securely. (Previous requirement met). All medications administered had been signed for. Staff said that they had undertaken training, which gave them the competencies to administer medications. Certificates were seen of the training staff had undertaken. Staff said that, if appropriate, people were enabled to maintain control of their medication, with self-administration risk assessments in place. People gave reasons why they felt unable to safely administer their own medication at this moment in time. Westfield Mews DS0000067775.V355716.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The complaints procedure was accessible and displayed within the home. Policies and procedures were in place on adult protection; this promoted and protected people who use the service. EVIDENCE: There was a comprehensive complaints procedure, this was in an appropriate format and was accessible to people. Complaint records showed two complaints had been received in the past year. There was evidence seen that these concerns had been addressed. The manager said they try to deal with any minor concerns or issues when raised by either people using the services or relatives. People said if they had any concerns they would feel very comfortable in speaking to the manager about them. Staff confirmed they were aware of protection polices and procedures, they were able to describe the action they would take on receiving any allegations. Records were seen of recent adult safeguarding training people had undertaken. This ensured people who use the service were safe and protected. Westfield Mews DS0000067775.V355716.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. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable environment that meets their needs. However two issues relating to safety mean that some people may not be safe in some areas of the home. EVIDENCE: The home was bright, clean and welcoming. It had homely touches in the shared rooms and people had personalised bedrooms. The bedrooms consisted of a lounge/ kitchenette, bedroom and en suite. People said the home was always kept clean and they felt comfortable living there. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 17 One person said they were concerned about the safety of the path outside the home. They had apparently slipped on the path. People at a meeting at the end of last year had highlighted the issue of the paths safety. We saw that the path was uneven which made it rather hazardous particularly in wet weather. We noted in one person’s room that there were a lot of trailing wires from small appliances. These were a tripping hazard and possibly an electrical hazard. No risk assessment was in place to assess the risk to the person who occupies the room or to staff. Westfield Mews DS0000067775.V355716.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. A stable staff group ensured continuity of care by staff that know the people who use the service. Staff had the skills and knowledge to fulfil their roles. Recruitment policies are followed ensuring the safety and protection of people who live at the home. EVIDENCE: Staff said that there were enough staff employed to meet peoples needs. People spoke highly of the staff team. People said that staff were “helpful and kind” and available when needed. Three staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. This ensured people who use the service were safe and protected. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 19 Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended. Development and training records were checked and discussed with staff. These showed what qualifications staff had achieved for example a number of staff had achieved National Vocational Qualification level 2 in care (NVQ). These records also showed when staff had completed mandatory training and refresher training. This meant that staff had the skills and knowledge to fulfil their roles. Westfield Mews DS0000067775.V355716.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. People who use the service experience good outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Overall management of the home was good, with policies and procedures in place to protect and safeguard people who use the service. EVIDENCE: The manager had good experience to enable her to manage the home well and had obtained the Registered Managers Award. As highlighted in the summary of this report the manager has now submitted an application to the CSCI to register as manager. This was a requirement made at the last key inspection. Westfield Mews DS0000067775.V355716.R01.S.doc Version 5.2 Page 21 Staff said they found the manager supportive. Comprehensive Quality assurance systems were in place to monitor aspects of the quality of care and services within the home, for example care plans and medication procedures. The area manager continued to carry out monitoring visits, and complete regulation 26 reports. These state what he found during his visit and who he spoke to, all were available at the home. Staff meetings and meetings involving people at Westfield Mews were held and minutes of these meetings were seen. Accident/incident records were being maintained and the manager was monitoring these records. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. Fire dill practices were occurring on a six monthly basis at the home. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the people. Westfield Mews DS0000067775.V355716.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 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Westfield Mews DS0000067775.V355716.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. Standard YA16 Regulation 12 Requirement The daily routines of the home must promote individual choice and freedom of movement. (Dispensing of medication) The premises must be safe and kept in a good state or repair internally and externally. (Footpath) Risk assessments must be undertaken and action taken to minimise tripping or electrical risks. Timescale for action 01/06/08 2. YA24 23 01/03/08 3. YA24 23 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations All records relating to a persons care plan and risk assessments should be held together. This will ensure that staff have all relevant information relating to a persons needs in one file. Westfield Mews DS0000067775.V355716.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 Mews DS0000067775.V355716.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. 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