Inspection on 14/12/05 for Westhaven Nursing Home

This inspection was carried out on 14th December 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

Westhaven Nursing Home 02/10/06

Westhaven Nursing Home 16/02/06

Westhaven Nursing Home 02/02/05

Westhaven Nursing Home 04/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westhaven Nursing Home 11-15 Queens Road Hoylake Wirral CH47 2AG Lead Inspector John McCabe 1Unannounced Inspection 14th December 2005 09:30 X10015.doc Version 1.40 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 Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 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 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. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westhaven Nursing Home Address 11-15 Queens Road Hoylake Wirral CH47 2AG 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) 0151 632 1737 0151 632 3758 Dove Care Homes Limited Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 34 nursing and 3 personal care within an overall total of 34. Date of last inspection 2nd February 2005 Brief Description of the Service: West haven is three Victorian terraced houses converted to use as a nursing and personal care home. The home is over two floors, and has a passenger lift. The majority of the rooms are large, single rooms, but none are en-suite. However, all are very nicely furnished, according to the individual residents preferences, and have hand-wash basins. There are garden spaces to the rear of the home and spaces for car parking. The home is set in a quiet road close to Hoylake main street, and is easily accessible to both local amenities and transport. ` Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 14/12/05 and commenced at 0930 hours and took 5 hours. The acting manager of the home was present throughout the inspection period. Personal files of both residents and staff were inspected, and a full tour of the building took place, which included the kitchen, laundry, and resident’s bedrooms. Staff and residents were spoken with as regards their view about the care home. The care home was clean tidy, and had adequate staffing levels to care for the residents. What the service does well: What has improved since the last inspection? What they could do better: Asbestos must be removed from the under stair ground floor cupboard, with all risks identified for residents and staff. The resident’s pre admission documentation and care plans must take into account the cognitive and psycho-social care needs of the resident. Resident chairs in the communal lounge are to low and pose a potential risk to both staff and residents when moving and handling residents. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 6 The rear gardens out houses are in a state of disrepair and pose a potential risk to staff and residents. Documents relating to Adult Protection should be available for all staffs. The registered person must provide a monthly written report on the conduct of 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 Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1,2,3,4,5. The Home’s Statement of Purpose is up to date and ensures that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis The residents’ pre-admission nursing/personal care assessment documentation is not comprehensive; this does not ensure that the skill mix of the workforce in the home can meet the resident’s identified care needs. EVIDENCE: All residents in the home are provided with a statement of terms and conditions, plus a contract when they move in to the home on a permanent basis. Residents are able to visit the home or have an overnight stay before they move in on a permanent basis. The home’s Statement of Purpose needs to be updated to reflect the new management structure of the home. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 9 The home’s senior nurses undertake a nursing pre admission assessment on residents before they are admitted to the home, to ensure care needs are identified. Other health care professionals known to the resident are also involved in the assessment. However, the nursing pre admission document does not refer to the cognitive, or psychosocial care needs of the resident. The home has recently admitted a resident with an Organic Psychoses (Alzheimer’s Disease). There is no mention of the results of the cognitive impairment the resident has suffered due to the disease, i.e., short term memory loss, speech, communications, wandering etc. Also, there is no mention that the resident has visual hallucinations. The pre admission nursing document because of it shortfalls does not identify Risks associated with the mental state of the residents. To ensure that the correct category of resident is admitted to the home, and the home has the skill mix of care staff to care for the resident, there must be a robust and comprehensive pre admission nursing assessment document. The document is also the basis of the first care plan for the resident once admitted to the home, and possible specialist training needs for staff. The acting manager will review and amend the documents. Care staff in the home undertakes mandatory and special care training, which is ongoing. Specialist care training includes dementia, stroke, diabetes, and challenging behaviours. This training is to help ensure that the assessed and changing care needs of the residents are met. . Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 7,8,9,10,11. Resident’s individual health, personal and social care needs are not clearly recorded, and do not provide care staff the sufficient information they need to meet the residents care needs. Personal support in the home is offered in such a way as to promote and protect the resident’s privacy, dignity and independence. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home and which is reviewed by the senior nurses on a monthly basis. Because the pre admission nursing documentation is not complete as regards the cognitive and mental state of the residents, the individual care plans do not reflect this. Though staff are aware of a resident having visual hallucinations, this is not been documented, nor is how carers should cope with the situation. Some of the residents do have early Organic Psychoses; the care plans do not include adequate details about mental health and the consequences of cognitive impairment of the resident. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 11 Daily health records are documented for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. Most of the care staff has undertaken training on tissue viability. The Primary Care Trust (PCT) tissue viability nurse will visit the home at any time if needs arise. Photographic and skin mapping evidence for pressure sores is recorded in the resident’s personal file, so as the healing process of the sore can be checked. At present no resident in the home has a pressure sore. All residents in the home can access their NHS entitlements; which includes, dentists, opticians, and chiropodist. Care staff will accompany residents for hospital or clinic appointments. GPs visit residents when needs arise. No resident in the home self medicates, all medications for residents are administered by the nurses in the home. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). Two first level nurses (or a suitable trained person) should record residents “Unwanted Medications” before being removed from the care home by the Clinical Waste Company. The manager of the home is to commence monthly audits of the resident’s medications. The homes accident book was reviewed; all relevant details were completed on each form. It is recommended that a monthly audit of resident’s falls be undertaken to ascertain whether falls are occurring more frequently in the day or night hours, and in which location in the home. Wirral Social Services have a designated person for “falls and Trips” and can give free advice to the care home on the prevention of falls within the home. On the day of the unannounced inspection, residents told the inspector that staff in the home were always courteous, respectful, and maintained their privacy and dignity when doing personal care. Some residents have asked for same gender carers to undertake personal care with them; staffs always fulfil this request. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12,1,3,14,15. Residents are encouraged to exercise choice and to have flexibility how they spend their day in the home. They also pursue leisure activities according to their choice and preferences. This allows independence and individuality for each resident. Residents receive a varied nutritious diet that is in accordance with their preferences. EVIDENCE: Currently, various care staff organise the residents activities, the acting manager is advertising for coordinator who will be responsible for the organisation of the residents activities. Residents in the home should be asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member, or care staff, should complete a “Getting to know you” questionnaire, which is a “Work life History” of the resident, and includes schooling, work, marriage, Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 13 hobbies, personal achievements, food likes and dislikes etc. This information should then be used to facilitate organised activities for the resident. When residents participate in organised activities, it should be recorded in the resident’s personal file. The residents had helped care staff to decorate the home for the Christmas celebrations. The home activities coordinator would benefit from contacting the National Association of Patient Activities (NAPA), for information, and literature of how to organise and document residents organised social activities. Visitors are allowed in the home at any reasonable time of day, and residents may entertain their visitors, in the communal lounges, or in their own bedroom. The residents informed the inspector that they enjoyed the variety of food in the home, and were looking forward to Lamb Casserole for lunch. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16,17,18. The home has a satisfactory complaints system, with evidence that residents feel their views are being listened to and acted upon. The home’s policy and training programmes for POVA, and Whistle blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: There have been no internal complaints, and no complaints were reported to the commission since the last inspection. The care home maintains information on the Protection of Vulnerable adults. This information is communicated to new employees on their induction course. There have been two internal complaints; no complaints were reported to the commission since the last inspection. The internal complaints concerned domestic issues and were quickly resolved by the acting manager and families of the residents. Many of the residents are encouraged to use their postal votes in the local or General Elections. The current information held at the care home regarding the Protection of Vulnerable Adults (POVA) is in need of updating. The manager was informed that, relevant up to date information on POVA could be downloaded free from the Department of Health (DH) website. The inspector was told that the home Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 15 did not have Internet facilities. The manager was also told that the Wirral Adult Protection office had publications, which should be acquired for the care home. On the day of the inspection there was evidence via the new staff induction booklet, that many of the staffs in the home had undertaken some training on POVA protocols, and the Whistle Blowing Policy. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 19,20,21,22,23,24,25,26. The standard of decor within this home is good, with evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents. EVIDENCE: The home is clean and tidy and efforts are being made by the home’s handyperson to improve the fabric and decor of the home, as resident rooms become vacant they are repainted and intensively cleaned. All communal bathrooms and toilets in the home provide privacy, and meet individual needs. The acting manager would like to convert one of the bathrooms into a walk in shower. Residents who share rooms have consented to do so. Mobile screens are available in all double room to ensure the privacy and dignity of the residents when personal care is being done. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 17 Resident’s bedrooms have been personalised with personal photographs and other memorabilia. The manager told the inspector that there was asbestos within the walls of an under stairs ground floor cupboard, which is to be removed in early January 06 by a recognised Asbestos removal company. The manager was asked to submit a written Risk Assessment to the CSCI, on the precautions being taken for residents, staff, and visitors on the day of the removal of the asbestos. The cupboard were the asbestos is present, is locked and not entered by staff or residents. The rear garden of the home has brick built Out Houses, which are in a bad state of disrepair, many are stacked with combustible items, and one building has no door. These buildings are dangerous for residents, staff and local children who can easily access the gardens. These buildings should be demolished or put into a state of repair, so as to ensure the health and safety of those who can access them. It is recommended that the homes stored water supply should be tested for Legionella Bacteria at least once a year. Residents’ armchairs in the communal lower ground floor lounge are low sitting to the ground. The inspector unobtrusively observed carers struggling to get residents into the chair and assist them out of the chair. These low chairs are a potential risk to both residents’ and staff when moving or lifting residents, they should be replaced with appropriate fire retardant chairs, which can make handling of the residents easier. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 18 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29.30. The standard of vetting and recruitment practices is in accordance with the NMS, with the appropriate checks being carried out on all new staff. This ensures that the residents are not put at risk. EVIDENCE: There is always a first level nurse on duty that is assisted by care staff and ancillary staff. The home recruitment policy is robust and in accordance with the NMS, all staff in the home has an up to date CRB/POVA enhanced certificate, so ensuring the safety of the residents. The inspector evidenced the Personal Identification Numbers (PINS) of all the registered nurses in the home, which was documented on Nursing Midwifery Council (NMC) stationary, all PINS were in date and valid. Mandatory and specialist training for all staff is ongoing in the home; and was evidenced in the personal files of the staff. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 19 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life, plus the turnover of care staff is low. The home regularly reviews aspects of its performances through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: An experienced first level nurse with 4 years of home care, management, manages the home; the acting manager will complete a NVQ Level 4 Care Management Programme in January 06. The acting manager has applied to the Commission to be registered, and registration should be complete by February 06. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 20 Currently there is a vacancy for 36 hours per week for care assistants. Staff and residents informed the inspector that, the home was run in an open, positive and transparent way. Both staff and residents have regular meetings with the manager; the meetings are minuted and actioned upon. All staff in the home have documented supervision six times per year, this ensures that all staffs have the opportunity to discuss with the manager, and other senior nurses, any issues, which can effect or improve the care for the residents. Documented supervision of all staff gives the staff and managers opportunities to discuss their own /or identified training needs. The registered person must provide a monthly written report on the conduct of the home. A copy of the report is kept in the home, and a copy forwarded to the Liverpool/Wirral Where possible residents or a family member look after financial affairs of the resident. The home doesn’t hold any bank accounts for individual residents. There is always a qualified First Aid person on duty in the home. Corporate management of the home should consider having Internet facilities within the home, this would assist the manager in sourcing information from various web sites on care plans, POVA, access to the DH, NMC, CSCI etc. The homes certificates of insurance and worthiness for machinery, gas, electricity, fire equipments, lift, hoists, Employers Liability Certificate were in date and valid. Residents and staff documents are kept secure in the home in accordance with the Data Protection Act 1998, thus maintaining confidentially. Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 21 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. 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement The registered person must ensure that the homes pre admission nursing documentation for residents includes aspects of the residents Psychosocial and Cognitive state. The registered person must ensure that residents care plans include aspects of Psychosocial care needs, and the results of Cognitive impairment, especially in those residents who are admitted with Organic Psychoses. The registered person must ensure that the Outbuildings in the rear garden are demolished, or put in state of repair, so ensuring the welfare, health and safety of the service users. The registered person must ensure that the low sitting resident armchairs in the ground floor lounge are replaced, to ensure the safety of both residents and staff. DS0000020915.V273128.R01.S.doc Timescale for action 1 OP3 14 31/01/06 2 OP7 15 31/01/06 3 OP19 23 31/01/06 4 OP19 23 31/01/06 Westhaven Nursing Home Version 5.0 Page 23 5 OP33 26 The registered person must ensure that a written report on the conduct of the home is forwarded to the Liverpool/ Wirral office of the CSCI. 31/01/06 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 OP8 Good Practice Recommendations It is recommended that home acquires up to date information regarding the Protection of Vulnerable Adults (POVA) It is recommended that homes water storage facilities be tested for Legionella Bacteria at least once a year. 1 2 OP26 Westhaven Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Nursing Home DS0000020915.V273128.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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