Inspection on 01/07/05 for Westhaven

This inspection was carried out on 1st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westhaven 27/07/06

Westhaven 12/01/06

Westhaven 22/02/05

Westhaven 16/09/04

Westhaven 12/02/04

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

CARE HOME ADULTS 18-65 WESTHAVEN 38b/38c Sandbach Road Congleton Cheshire CW12 4LJ Lead Inspector Julie Porter Unannounced 1st July 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westhaven Address 38b/38c Sancbach Road Congleton Cheshire CW12 4LJ 01260 298157 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) East Cheshire Housing Consortium Mrs Caroline Doolan Care Home 8 Category(ies) of MD Mental Disorder (8) registration, with number MD(E) Mental Disorder over 65 (8) of places WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of Service Users must not exceed 8 2. 8 of the Service Users may be MD 3. 8 of the Service Users may be MD(E) Date of last inspection 22 February 2005 Brief Description of the Service: Westhaven is a care home for adults/older people with mental health needs. It opened in 1990, and is run by East Cheshire Housing Consortium. This organisation also provides a range of other residential and sheltered accommodation within the Macclesfield and Congleton areas. Westhaven is located within a small sheltered housing complex, in a residential area off Sandbach Road. It is within walking distance of a local supermarket, post office and public house; it is also on a public bus route into Congleton town centre. The home is situated in pleasant and well maintained open-plan grounds, and has a small private garden at the rear. Bedroom accommodation for service users is on the first floor of both houses, and access to these areas is via staircases. Ground-floor accommodation comprises two lounges, two dining rooms, two kitchens and two utility rooms and the two properties are linked by an office for staff. There are four separate toilets between the two floors, and two bathrooms. Standards of décor, furnishings and fittings were good throughout the premises, as were standards of hygiene and cleanliness. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 1st July 2005 and involved a tour of the building, conversations with five residents and more in-depth conversations with two of the residents regarding their care. Two members of staff were on duty on the day and a Registered manager from another home within the organisation contributed to this report. Records in the home were also checked as part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 6 Agreements need to be in place regarding maintenance of the property particularly when it may affect the health safety and welfare of the residents who are tenants in the home. 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. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 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 standard(s) 1 - 5 Residents have their care needs assessed, they are given information about the home and are encouraged to visit before they make a decision to move there. EVIDENCE: Individual contract are available between Contour Homes and each resident, this gives information about the annual/monthly cost of living in the home. Separate contracts are available for the cost of staff support. The home has a new service user guide available, which is informative and provides the reader with information about living in the home, the staff and what to do if they were unhappy. One residents’ file looked at contained the original assessment of her needs and the home had developed this further during the trial period of her stay. She said that she had lived somewhere else before and this was the best, that “she did not ever want to leave.” WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 -10 Residents are supported with their chosen lifestyle, they are involved in planning their care and activities, encouraged to assess the risks involved and make decisions about their actions. EVIDENCE: Care files, health files and a record of the residents finances are kept in a locked cabinet in the office. A record of the finances held on behalf of individual residents’ was looked at and was being maintained correctly. Residents’ care files showed evidence of their involvement in the planning and this was confirmed by two of the residents spoken with on the day of the inspection. One said that she sits monthly with the staff and looks at the plan for her future particularly regarding her health. The records confirmed that this was in fact happening. Staff were also observed throughout the day promoting independence and encouraging residents’ to make decisions. The home has good links with other professional health workers like Doctors; community nurses, including Psychiatric nurses; nursing staff at the diabetic clinic; chiropodists and opticians. Evidence of their involvement was seen on the residents’ files. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 11 -17 Residents are encouraged to make decision about how they live their lives. EVIDENCE: Local shops, post office and a pub are within walking distance of the home, some residents are able to go there on their own. One resident spoken with said she enjoyed shopping and that near to the shops was a seating area where she enjoyed spending time talking with people who lived in the area. Although no visitors came to the home on the day of the inspection, family and friends are encouraged to spend time with their relatives and friends. One resident said that her son and granddaughter regularly spend time with her, and that she visits a friend once a month. Although the home has two lounges, further seating areas have been created to meet the needs of the residents preferring quiet time or specific T.V. programs. Televisions are available in each of the lounges, it has been a past recommendation that the T.V’s need to be bigger to suit the room size, but as the cost of the television is included in the schedule of costs paid by the residents, the home must be sure the residents want this. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 11 Residents can choose to spend time alone in their own bedrooms and staff were seen knocking and waiting before entering. A conversation with one resident and the minutes of one of the residents meetings raised the question as to whether she could have a pet, unfortunately the contract with the housing association is clear in that “pets are not allowed.” Residents help themselves to breakfast and lunch and food was available to cater for individual choice and diet. Evening meal is prepared and cooked by the staff with help from the residents when they are able. Rotas for domestic duties i.e. emptying the dishwasher, setting the table, washing and ironing were seen in the kitchens. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 -20 Staff have been employed by the home for a number of years so know the residents well, residents feel confident and comfortable that the staff look after their interests. EVIDENCE: Five residents were at home on the day of the inspection and all were spoken with. Two residents were able to participate fully in discussions about their lives in the home, and talked about what they were able to do for themselves and what they needed help with. Both said they felt happy that they lived there and life for them was better since moving to the home. One resident said she enjoyed the company of others and the company of the staff. The other said she liked her own company but was grateful that the staff were around should she need them for advise. She said that the staff were “fantastic” and she could not want for anything more. Residents have their own medication in locked containers in their bedrooms and are encouraged to take it under close supervision. Residents administering their own medicines do so following an assessment of the risk. The home has developed their own policy on medicine administration since the last inspection and it is now clear to staff of the action they should be taking. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 -23 Without suitable training for all staff on protecting people from abuse, residents and staff are vulnerable. The complaints procedure does not record all complaints made and therefore cannot demonstrate that is effective. EVIDENCE: Policies about adult protection and “whistle-blowing” are available in the home, however the adult protection training due to take place in April 2005 has not yet happened, without appropriate training the staff and residents are vulnerable. The home has amended its complaints procedure and responds to written complaints effectively, but does not always record verbal complaints made by residents and the action taken. Therefore is unable to demonstrate how it is improving the service by acting on residents’ wishes. See requirement 1 & 2 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24 -30 Residents live in a homely environment, maintenance and repairs to the home are not responded to promptly which puts residents safety at risk. EVIDENCE: Westhaven is situated in a small sheltered housing complex and local shops are within walking distance of the home. The home is two houses each having a lounge, dining room, kitchen, utility room and toilet on the ground floor, four bedrooms, a bathroom and another toilet upstairs and the home is linked together by a central office. On the day of the inspection the home was generally clean, tidy and homely. A number of maintenance / replacement matters need to be dealt with as follows; one bedroom needs decorating and the carpets in both of the lounges were covered in cigarette burns and need replacing. The kitchen in 38B had a number of drawers missing, the cabinet doors had exposed chip-board and the worktops were chipped, repairs need to be made to the kitchen or the kitchen needs replacing as it’s current condition poses hygiene and infection issues. An immediate requirement was left at the home as requirements made by the inspecting fire officer on 2nd February 2005 had still not been resolved, regarding self-closures and seals on bedroom doors. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 15 Se requirements 3 & 4 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 -33 & 35 Staff have been employed at the home for a number of years and have developed an understanding of the residents needs. EVIDENCE: Residents spoken with knew staff by name and knew what their jobs were, they knew if they had any problems who to speak to and felt confident that the problem would be resolved before they would have to speak with the manager. Neither resident I talked with said that they would have a problem speaking with the manager if necessary. The staff have worked for the company for a number of years and were enthusiastic about the training available to them, all staff employed at the home have either achieved or are working towards and NVQ qualification. One member of staff informed me that the most recent training she had done was about providing support for people with mental health problems. I was informed by another manager from East Cheshire Housing Consortium that all staff had completed training as follows; moving and handling; 1st Aid; food hygiene, and fire training. Training relating to the protected of adults from abuse has not yet taken place. See requirement 2 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 17 Training certificates are held on personnel files and not inspected this visit. A matrix should be developed to create a rolling program for staff training. See recommendation 1 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 -42 The residents best interest are important to the staff in the home, however their safety may be compromised by delays in repairs to the property. EVIDENCE: The registered manager has got the NVQ Registered managers award, the records checked about accidents, fire alarm checks and emergency lighting were well maintained. The atmosphere in the home was positive and the staff were observed encouraging residents to make their own decisions. Residents said that they have regular meetings and are involved in decision making about life in the home. A director of the company visits the home monthly in accordance with Regulation 26 and a report is available. Policies and procedures have been developed and at any time when these are updated staff confirmed they are discussed during supervision. WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 19 The staff report maintenance and repairs needed at the home promptly, but the housing association does not respond quickly to matters concerning health and safety for the residents, for example requirements made by the fire officer and hygiene matters relating to the kitchen in 38B. See requirements 3 & 4 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 WESTHAVEN Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 x F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 22 Regulation 22 Requirement Timescale for action 30/09/05 2. 23 18 3. 24 23 4. 24 23 The staff must ensure that any complaint is recorded, investigated and a record kept of the outcome All staff must receive training on 30/09/05 protecting people from abuse and on adult protection procedures. Plans must be drawn up for each member of staff to receive training relevant to the role they perform. The home must have a planned 30/09/05 schedule of maintenance to ensure the residents live in a safe comfortable home regarding replacing or repairing the kitchen and redecoration The home must ensure the immediate safety of the residents by taking appropriate action to contain fires as required by the fire brigade 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 Good Practice Recommendations F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 22 WESTHAVEN 1. Standard 32 The home manager should develop a training matrix to access staff training records easily WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire, CW9 7LT 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 WESTHAVEN F51 F01 S6685 Westhaven V233291 160605 Stage 4.doc Version 1.30 Page 24 - 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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