Inspection on 08/04/05 for Westfields

This inspection was carried out on 8th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westfields 04/07/06

Westfields 22/09/05

Westfields 08/12/04

Westfields 19/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westfields Westfield Road Swaffham Norfolk PE37 7HE Lead Inspector Christopher Handley Unannounced 8 April 2005 9.30am 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westfields Version 1.10 Page 3 SERVICE INFORMATION Name of service Westfields Address Westfield Road Swaffham Norfolk PE37 7HE 01760 721539 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Norfolk County Council - Community Care Mrs Glenis Tudor Care Home 40 Category(ies) of Old Age (40) registration, with number of places Westfields Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The home to accommodate 40 Service Users who are old people not falling within any other category. Date of last inspection 8 December 2004 Brief Description of the Service: Westfields is a purpose built Local Authority Home providing accommodation for 40 elderly residents.The accommodation is on the ground and first floor. There are 40 single rooms. The home is set in its own grounds, with a car park at the front and side of the home.The home has a small rehabilitation unit on the first floor.The home receives nursing care from the District Nurse and medical services from GP practices. The home is situated adjacent to the town centre of Swaffham. Westfields Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, and was carried out as part of the annual inspection programme. A tour of the premises was undertaken. Five residents, five staff, and four visiting professionals were spoken to. The home has been redecorated since the last inspection and looks much brighter, and less institutional as a consequence. A wide range of documentation was examined with the Manager. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westfields Version 1.10 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westfields Version 1.10 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3, & 6 All residents get a copy of the Service Users Guide The home has comprehensive Statements of Purpose. Pre admission assessments are undertaken on all prospective residents. The home has clear arrangements for residents who are admitted for intermediate care. EVIDENCE: All residents are provided with a wide range of information about the home. If needed a member of staff will go through this documentation with them. Some of this documentation was seen in the residents rooms. One resident said” it told him all he wanted to know.” The Norfolk County Council booklet “Tell us what you think” contains a wide range of useful information for residents, and is available in the reception area of the home. Westfields Version 1.10 Page 8 Pre admission assessments are undertaken by the Care co-ordinators The documents used are now headed “Confidential Information”. The documents are detailed and comprehensive. These assessments are carried out by arrangement and identification is taken by the member of staff. Residents admitted for intermediate care are admitted to a section of the home, where they are cared for by staff who have specific training and where there is a wide range of rehabilitation facilities. Westfields Version 1.10 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8, 9, & 10 The care plans have improved but this needs to continue. The health care needs of residents are fully met. The home has a safe and effective medicine system. Residents are treated with respect and privacy. EVIDENCE: All residents have an individual care plan, three of which were read. The plans, have the essential elements of assessment, planning, implementation and review, and a wide range of specific assessment. All folders are now marked “Confidential information” and are kept secure. In the care plan section, not all the documentation is uniform and the Manager needs to address this. The health care needs of the residents are met and are recorded. These needs are met by professionals visiting the residents in the home or by residents attending the appropriate clinics or hospital, with the appropriate treatment then being provided. The medicine system, is safe, and effective. The medicines are kept in a locked room. The temperature of this room has been too warm in the past, but on the day of the inspection the temperature was correct. Westfields Version 1.10 Page 10 Residents interviewed said they were always treated with respect and the provision of privacy, e.g. knocking on doors, forms part of the daily life in this home, and this was witnessed several times during the process of this inspection. The Manager confirmed the importance of privacy formed part of the training of staff. Westfields Version 1.10 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The home provides a nutritious and varied menus for residents. EVIDENCE: The menus were read, they appeared varied, nutritious, and interesting. Special diets are provided , but are not recorded on the menus seen. The residents interviewed spoke highly of the meals, adding that there was a wide range of choice and that there was always an alternative. Morning drinks were being served during the process of this inspection If needed the Manager would obtain the advice of the Dietician. Westfields Version 1.10 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has an effective complaints policy. The home has Norfolk County Councils Adult Abuse Awareness policy. EVIDENCE: The complaints procedure is displayed in the home. The detailed advice for residents on how to make a complaint is clearly set out in Norfolk County Councils booklet “Tell us what you think” . Two residents interviewed were aware of how to make a complaint and that there was a “ little book” which tells them how to do so. The home follows Norfolk County Councils Policy and Procedure in regard to Adult Abuse. Awareness The Manager, and all the staff have undertaken training, and the Manager is now a recognised trainer in Adult Abuse. Westfields Version 1.10 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25,&26. The home is suitable for its purpose. The grounds are accessible and well maintained. The home has a safe and effective laundry. EVIDENCE: Based on the evidence of the Manager, the building complies with the requirements of the local fire service, who have recently undertaken an inspection of the home and found that the standards are met. The home complies with the environmental health department standards. The grounds were neat and tidy and the lawns are well maintained. There is good access to the gardens for all residents, including wheel chair users, and this was observed during the process of the inspection. A tour of the home was carried out. It has been decorated since the last inspection and this has greatly improved its appearance, making it lighter and less institutional. At present a list of routine maintenance is being drawn up. Westfields Version 1.10 Page 14 Ten rooms were seen with the approval of the residents concerned. All the residents spoke very highly of their rooms and have successfully personalised them. The rooms are individually and naturally ventilated. Residents have good views over the gardens. All pipe work and radiators are protected. All windows have restrictors. Many of these safety devices were seen during the tour of the home. The Manager said that the lighting meets the recognised standard (lux 150).There is emergency lighting throughout the home. Water is stored at 60C and distributed at 50C. Observations showed that the home was neat, clean, tidy and odour free. The home has a well equipped laundry, which meets all the standards. The home has polices and procedures for the safe handling of clinical waste, dealing with spillages, and provision of protective clothing. These polices are in the Manager’s office. Westfields Version 1.10 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 &30 The home has an effective training programme for staff. EVIDENCE: The Manager stated that there are 4 members of staff who have NVQ2, and there are 6 members of staff currently undertaking NVQ2. There are 2 members of staff who have NVQ3, and 1 member of staff who is undertaking it. These figures give a total of 6 staff who have successfully completed NVQ, which is an increase of 1 since the last inspection. This gives a total of 25 of staff who have NVQ training. The target required is 50 . The Manager’s view is that the training has made the staff think more about why they carry out task in a particular way. The Manager is currently undertaking the Registered Managers Award. Two members of staff spoke to the Inspector about the training and said that they recognised this had improved their knowledge, and were pleased to have undertaken it. Westfields Version 1.10 Page 16 The home’s induction and foundation training programme meets NTO specification, and copies of this documentation were been seen. Other training provided includes First Aid, Fire Training, Moving and Handling Sensory Impairment, and Reminiscence. The staff spoken to recognise the benefits of ongoing training. and it does appear that the ethos of training is getting stronger To further enhance the knowledge of the resident group it is recommended that the Care Coordinators, because of the pivotal role they play undertake specific training in Care for the Elderly. Westfields Version 1.10 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 33 The Manager is an effective Manager of this home. The home has a recognised system of Quality Assurance, Investors in People. EVIDENCE: The Manager said she has worked with older people for over twenty years and has been the Manager of this home for four years. She is responsible for this home only. The Manager has a job description, which was seen. There are clear lines of accountability within the home and with external management. The residents interviewed spoke highly of the Manager. Staff spoken to see her as the leader of the home to whom they can turn to for advice. At present the Manager is undertaking the Registered Managers Award. There is continuous self-monitoring in the home undertaken by staff. Westfields Version 1.10 Page 18 Residents are informed of inspections. Norfolk County Council have successfully gone through the process of applying for Investors In People, and the home forms part of that organisation, which has its own monitoring and reviewing processes. Westfields Version 1.10 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 x 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x x x x x Westfields Version 1.10 Page 20 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 Standard 15 Regulation 4,13 Requirement Special Diets to be recorded. Timescale for action 4 weeks 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. 2. 3. 4. 5. Refer to Standard 7 25 28 30 31 Good Practice Recommendations That the content and structure of the Care Plans be made uniform. That a list of routine maintenance is drawn up. That the NVQ training programme continue. That Care Co ordinators be provided with training which will increase their knowlegde of careing for elderly people. That the Manager continue with the Managers Training Award. Westfields Version 1.10 Page 21 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 Westfields Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!