Inspection on 03/05/05 for Westhaven

This inspection was carried out on 3rd May 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 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

Westhaven 10/04/07

Westhaven 19/09/05

Westhaven 08/12/04

Westhaven 07/08/04

Westhaven 26/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Westhaven 68 Blackborough Road Reigate Surrey RH2 7BX Lead Inspector Mrs S McBriarty Unannounced 3rd May 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 H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westhaven Address 68, Blackborough Road Reigate Surrey RH2 7BX 01737 221503 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) Millstead Care Ltd Amanda Vivienne Finch Care Home 6 Category(ies) of LD - Learning Disability (4) registration, with number of places LD(E) - Learning Disability over 65 (2) Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 3. The age/age range of the persons to be accommodated will be : 41-65 years & two over 65 years Date of last inspection 8th December 2004 Brief Description of the Service: Westhaven care home is owned and managed by Millstead Care Limited and is registered for six(6) people with a learning disability. The home has a fully equipped kitchen, dining room, living room and six single bedrooms. The property is located in a pleasant residential area in close proximity to two local towns, Reigate and Redhill. The home has its own transport which is accessible for current service users. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first for 2005 – 2006. Previous reports are available on request from CSCI. During this inspection three staff members and four service users were spoken to. The manager was not available for this inspection. Documents sampled during the inspection included, service user files, care plans, risk assessments, daily diary and finance records. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 6 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 H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 7 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) 1,2,3,4,5 Prospective service users are given the information they require to make a decision about moving into the home. The statement of purpose requires updating. EVIDENCE: The statement of purpose was available, however the copy was not accessible and did take some searching before being found. The homes complaints policy requires updating as it includes complaints made with regard to the protection of vulnerable adults. This is also noted in the section on Concerns, Complaints and Protection. Prospective service users are able to visit the home and spend time there before making a decision about staying there. The current service users had assessments that had been undertaken prior to their placement. Each service user had a written contract with Millstead Care Limited that they had signed. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 8 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, 7, 9, 10 Care plans were in place, further progress on care plans and risk assessments was required. All confidential records were held appropriately. EVIDENCE: The care plans had very recently been updated, the service users had not signed them. The service users had signed all other personal documents. It is required that wherever possible service users sign their care plans. It is also recommended that staff assist service users to do so as soon as possible after the completion of any revised or new care plan in order that this is not overlooked. One service user had a specific health related issue that had not been risk assessed. The inspector was informed that the staff members were aware of the issue. However it is required that a risk assessment be provided. The service users were coming and going throughout the day and were making choices and decisions that the staff members responded to quietly and efficiently. Choices included whether they wished to go out for a ride in the transport whilst staff members assisted other service users to access services. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 9 Some of the service users were out when the inspector arrived at the home, on their return one person wanted to ensure that the inspector knew “ I am happy here, very happy”. The home has a key-worker system in place. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.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) 12, 13, 14, 15, 16, 17 A wide variety of activities were available to the service users. A simple lunch was sampled and the menus seen offered a varied and nutritious choice. Further progress is required in some areas. EVIDENCE: A number of activities took place. The records seen by the inspector noted that each of the service users had differing activities in most instances. These included work, cooking, horse riding, attending a social club and church. One of the service users spoken to talked about people they had known in the past and had lost contact with. The staff said that they were seeking to try and find some of their old friends. Where family members were involved the contact remained and was encouraged. Privacy was supported and one care plan noted that one to one support to talk through problems was needed. During the inspection a request was made for this support and staff immediately agreed. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 11 Each service user file noted whether the people wanted to have their own key to their bedroom door and where this was required by the service user provision was made. The staff dealt with the service users weekly finances. Records were kept regarding how much money they had spent. The staff member spoken to was unaware of where the money came from and it was classified as a ‘petty cash sub’. It is required that both staff and service users are made aware of where their money comes from and the level of income they are entitled to each week. The information must be recorded on the service user files. Any monies transferred from service user savings was noted in the communication book but not the finance sheet. It is required that the finance sheet also notes where the money came from as well as the amount. The staff members were observed talking to the service users throughout the day and it was clear that they had developed a good relationship. Some inappropriate language was heard being used and occasional records in the communication book were also inappropriate. Staff members were heard to call service users ‘sweetheart’ or ‘darling’ and notes in the book stated that, for example, a person was ‘grumpy’. The menus seen offered a varied and nutritious diet. The home had just introduced its summer menu. On the morning of the inspection one of the service users had been cooking and chose to eat the results for her lunch. A simple lunch was sampled and it was noted that each of the service users present was able to choose what they wanted. There was evidence of plenty of fresh fruit. The kitchen itself was not inspected on the day. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.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, 19, 20, 21 The personal care needs of service users were being met. Details of their health needs were available. Policies and procedures were in place to support those who may be ageing, ill or dying. EVIDENCE: The care plans and staff members knowledge of service users and their support needs was evident during this inspection. Service user files recorded access to health care for example, doctors, dentists and chiropodists. Medication was stored correctly and all related records were correct. It was recommended that where PRN (as required) medication is necessary a note is also made on the reverse of the medication administration record sheet. A note is made in the communication book on each occasion. The home has a policy in place for those who may be ageing or dying. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.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 Further progress is required in both areas. EVIDENCE: It was not possible to check training provision during the course of the inspection. The manager had the keys to the filing cabinet and they were therefore not accessible to any other staff member. It is required that a member of staff be nominated in the absence of the manager to hold the keys to enable access for inspection purposes. The home’s protection of vulnerable adults procedure required further work. At the time of the inspection the procedure noted only that staff must inform the manager or person in charge. The complaint procedure also required further work; the procedure also includes complaints involving adult protection procedures. These must be dealt with within the local authority adult protection procedures and not the homes internal complaint procedure. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.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, 25, 26, 27, 28, 29, 30 The home was clean and well presented. The toilets and baths available were adequate to the needs of the service users. Further progress is required with regard to privacy. The garden required further work. EVIDENCE: A tour of the home took place and the service users rooms were personalised. The room seen were of a good size and were clean and airy. The downstairs toilet did not have a lock and did not offer the privacy required when in use. There was no way of knowing if the toilet was in use other than opening the door. A requirement has been made that a lock is fitted. The dining room, living room and kitchen were of a good size, clean and light. None of the service users required specialist equipment. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 15 The inspector was informed that the garden refuse in the grounds had been created by the building work that had been carried out by neighbours. However the refuse was in the garden of the home creating a trip hazard and was unsightly. A requirement has been made to remove the rubbish and make good the area of fencing that had been removed. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.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) It was not possible to assess these standards during this inspection as no records could be accessed. EVIDENCE: Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 17 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) 40, 41, 42 Further progress is required before these standards can be met. EVIDENCE: Some of the records were not up to date or had not been undertaken, for example the specific risk assessment, a requirement has been made. The homes policies and procedures are accessible to staff and service users. The staff had signed that they had read and understood the contents of each of the policies. It has been noted that two of the policies seen required further work. During the inspection the hot water was tested. The homes thermostat went up to 60 degrees centigrade and when tested the temperature of the water went to that limit. As a number of the service users required assistance to ensure their bath water was not too hot as they were unable to safeguard Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 18 themselves an immediate requirement was made for safety devices to be fitted to regulate the temperature of the water. None of the service users require personal physical care, however it is required that paper towels are provided in a dispenser in the bathrooms and toilet. At the time of this inspection some paper towels were seen. Only the kitchen had a dispenser and staff washing their hands in the downstairs toilet then had to move to the kitchen to dry their hands. A communal towel had been provided in the toilet. As already noted the person using the facility could not lock the downstairs toilet. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 19 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 2 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 2 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 2 3 3 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westhaven Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x 2 2 2 x H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 20 NO 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 YP1, 22 Regulation Requirement Timescale for action 30th June 2005 2. YP6 3. YP9 4. YP12 5. YP16 6. YP23 7. YP27 4(1)Sched The registered person must ule 1 update the complaints procedure (14), 22 and remove that part of the procedure that includes the protection of vulnerable adults. 15 The registered person must ensure that care plans, wherever possible, are signed by the service user. 13(4)(b) The registered person must ensure that a risk assessment is provided for the specified service user. 17(2) The registered person must Schedule ensure that the finances for each 4(9)(a) service user are made clear and recorded on their file. All records kept must be up to date and documented. 12(4)(a) The registered person must ensure that all records use appropriate language and that staff members use the preferred choice of address to service users. 13(6) The registered person must review and update the homes protection of vulnerable adult procedures in line with multiagency procedures. 12(4)(a) The registered person must H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 30th June 2005 17th June 2005 30th June 2005 30th June 2005 15th July 2005 30th June Page 21 Westhaven 8. YP28 23(2)(o) 9. YP42 13(3) 10. YP42 13(4)(a)( b)(c) 11. YP32 17(3)(b) ensure that a lock is provided to the downstairs toilet. The registered person must ensure that grounds are cleared of garden refuse and the boundary fence made good. The registered person must ensure that the bathroom and toilets are provided with paper towel dispensers. The registered person must ensure that safety devices are fitted to the hot water outlets in the service users rooms, toilets and bathroom. The registered person must ensure that a member of staff has access to the staff personnel and training files in the of the manager to ensure they open to inspection. 2005 15th July 2005 29th July 2005 16th May 2005 (immediate ) 31st May 2005 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. Refer to Standard 20 Good Practice Recommendations It is recommended that whenever as required medication is used that a note be meade on the reverse of the medication administration record. Westhaven H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 H58_v221217_Westhaven_s13822_030505_stage4.doc Version 1.30 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. 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