Inspection on 09/03/06 for Westgate

This inspection was carried out on 9th March 2006.

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

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

Other inspections for this house

Westgate 26/04/07

Westgate 26/10/05

Westgate 19/01/05

Westgate 09/08/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Westgate Westgate 5 Ellenborough Crescent Weston Super Mare North Somerset BS23 1XL Lead Inspector Paul Grey Unannounced Inspection 9 of March 2006 09:30 th Westgate DS0000008101.V280521.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 Westgate DS0000008101.V280521.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. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westgate Address Westgate 5 Ellenborough Crescent Weston Super Mare North Somerset BS23 1XL 01934 621952 NONE i.hallscott@btinternet.com 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) Mr Iain Hall-Scott Mrs Jacqueline Hall-Scott Mr Iain Hall-Scott Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (10) Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: Westgate is a pleasant Victorian terraced building located within easy reach of the town centre and local amenities. The home offers care to older service users with enduring mental health issues. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Westgate is a sister service to Shallcott Hall. In common with its sister home, Westgate provides a high standard of residential care for service users. This inspection was conducted in the absence of the manager over a three-hour period. The Inspector conducted a tour of the premises, spoke with service users, spoke with staff and audited care files. The Inspector notes that the administration and documentation processes are essentially the same for both homes. Although the homes are inspected individually there are many overlaps regarding documentation. This may be reflected in this report. That the home continues to receive positive feedback from service users. The Inspector noted the homes excellent administrative infrastructure, up-to-date records, policies and procedures and generally a high standard of care. The Inspector commends the standard of care in the home. What the service does well: What has improved since the last inspection? What they could do better: Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 6 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. Westgate DS0000008101.V280521.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 Westgate DS0000008101.V280521.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): 1,2,3 Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Service users know the home they choose will meet their needs and aspirations. EVIDENCE: As stated in the inspection summary, a good deal of documentation is shared between both Westgate and Shallcott. As a consequence many of the inspection findings are mirrored in both reports. The Inspector would point out however that the documentation is personalised to each home and not simply replicated. Westgate retains its excellent statement of purpose. This exceeds national minimum standards. The Inspector was particularly impressed by the fact that the general philosophy of the home is so clearly reflected throughout care. As a consequence the Inspector noted the home exceeds national minimum standards. The home has excellent service user assessment. These are particularly detailed, comprehensive and address the full therapeutic spectrum. The Inspector noted once again that service user assessments were regularly Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 9 reviewed and kept up-to-date. The home had also integrated thorough care programming approach into their care planning. The Inspector noted evidence that service users were positively involved in the assessment process. The Inspector was able to track assessment and care delivery via assessment documentation and care plan documentation. The Inspector noted the home exceeds national minimum standards. Evidence from service user statement and documentation clearly outlines the homes capacity to meet service users assessed needs. The homes strength is its ability to assess service users and identify those whos needs the service can most strongly meet. The Inspector noted clear evidence that staff communicate effectively with service users. The Inspector also noted evidence that service users are informed and supported to use an advocate if necessary by the home. The home exceeds national minimum standards. Westgate DS0000008101.V280521.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, 10 The home assesses service users changing needs and personal goals. These are reflected in the service users plan of care. Service users make decisions about their lives with assistance as needed. Service users are supported to take risks as part of an independent lifestyle. Information pertaining to service users is stored appropriately and service user confidences are kept. EVIDENCE: The Inspector audited two care files, spoke with 2 service users and one staff member. The Inspector noted plans set out house service users assessed needs would be met through positive interventions and support. Any potential restrictions on freedom were clearly outlined in the user files and signed by the service users. The plans also addressed risk assessment, general assessment and a range of methods to focus on positive feedback to the service user. The plans of care were presented in clear plain English. Service users were aware of the plans of Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 11 care and the name of a key worker. All plans of care were reviewed regularly with the service user. Service users are assisted in making day-to-day decisions where needed. This is documented clearly in the plans of care. The Inspector noted no undue restriction on service users rights through their care plans. The Inspector found evidence as to how service users individual choice was made, evidence for this was also available from service user statement. This was good practice. The Inspector noted comprehensive and up-to-date risk assessments. Risk assessments could be case tracked back to the assessment and care planning process. Risk assessments were of a high standard. Risk assessments appear to indicate that the home responds rapidly to identified risk. The Inspector noted the home has policies and procedures regarding the handling of confidential information. Service users records were stored securely, records appeared accurate and up-to-date. Staff spoken with knew that care files were confidential. Westgate DS0000008101.V280521.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): 11,13, 15, 16 Westgate provides service users with opportunities for personal development. Service users are part of the local community. Westgate supports service users to establish appropriate relationships both in and out of the home. The home respects the service users rights, this is recognised in the daily lives. EVIDENCE: The Inspector spoke with 2 service users and one staff member regarding the standards. The Inspector also read care files. Service users informed the inspector that they were encouraged and supported to establish relationships outside of the home. The inspector noted the in service user files that service users were supported to attend courses or activities out of the home should they wish. Service users are also encouraged to attend the local church if they desire. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 13 Service users are encouraged to take part in a range of activities outside of the home where they so desire. Staff support is available for service users wanting to engage courses at the local college etc. The manager informed the inspector that service users are supported to maintain family links. Service users spoken with a time of inspection said that friends or family are made welcome by the staff team. The inspector noted that service users are encouraged to develop relationships both inside and outside of the home. Service users are supported, should they wish, to establish a normal relationship with individuals outside of mental health services. The home is run very much along an extended family type community. Service users valued this, and felt that the home had achieve a balance between commonsense rules and individual freedom. Service users valued the home community atmosphere particularly at mealtimes. The inspector noted that the eating arrangements were designed so that everybody eight together at the same table. This helped build and reinforce a sense of community. During inspection staff knocked on all rooms before entering and used service users referred name. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 14 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): 20 Service users are protected by the homes policies and procedures. EVIDENCE: The Inspector checked the homes procedures for handling and administering medication. The Inspector noticed these were safe and well organised. the Inspector noted clear records were kept of medication and that these contained no obvious errors, omissions all crossings out. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse, neglect and self harm. EVIDENCE: The Inspector noted robust procedures in place for the reporting of suspected abuse. The Inspector noted staff have received training to identify what constitutes abuse and steps to be taken in the event of it. The Inspector also noted evidence of a whistleblowing policy and the no secrets document. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26, 30 The home is pleasant, comfortable and safe. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. The home was clean and hygienic throughout. EVIDENCE: Westgate is situated in a pleasant Edwardian Crescent a few houses away from Shallcott Hall. Externally both buildings are similar on a similar sized plot. Westgate is a pleasant domestic property, with slight modifications to improve communal living. The home itself is bright, pleasant and homely. Click okay The Inspector was able to visit service user bedrooms whilst having a tour of the premises. Service user bedrooms had sufficient furniture and fixtures to meet national minimum standards. These were of reasonable quality. The service users could bring their own furniture should they choose, (subject to health and safety and fire regulations). Service user bedrooms were lockable Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 17 with the service users retaining their own key. Staff at the home had a pass key for emergencies. The Inspector noted service users bedrooms were of sufficient size to meet national minimum standards. The premises were clean and hygienic throughout. During inspection the Inspector noted no foul odours. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Service users benefit from clarity of staff roles and responsibilities. Service users were the homes recruitment policies and procedures. EVIDENCE: There were a number of standards the Inspector was unable to audit as this unannounced inspection was conducted in the absence of the manager. The inspector noted that all staff had clearly defined job descriptions and clearly defined responsibilities within the home. The inspector found evidence to indicate that staff have sufficient time to develop relationships with service users they support and are able to meet those service users needs. Staff spoken with a clear understanding of the roles and any limits on their knowledge and skills. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 19 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): 38 Service users benefit from the ethos and leadership of the home. EVIDENCE: In the absence of the manager, the Inspector audited only standard 38. Staff and service user feedback regarding the management style of the home was positive. Service users felt valued, involved and felt they understood the management practices of the home. Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 20 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 4 2 4 3 4 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x X 3 X X X X X Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Westgate DS0000008101.V280521.R01.S.doc Version 5.1 Page 23 - 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!