Inspection on 16/02/06 for Westhaven Nursing Home

This inspection was carried out on 16th February 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 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 Nursing Home 02/10/06

Westhaven Nursing Home 14/12/05

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 Julie King Unannounced Inspection 16th February 2006 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.V282857.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 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.V282857.R01.S.doc Version 5.1 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.V282857.R01.S.doc Version 5.1 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: Westhaven 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.V282857.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by CSCI Inspector Julie King, and took place over 5 hours. The acting manager, Miss Margaret Stewart, 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. A walk around the exterior of the building was also done. 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: Resident chairs in the communal lounge are to low and pose a potential risk to both staff and residents when moving and handling residents. The rear gardens out houses are in a state of disrepair and pose a potential risk to staff and residents. Improvements are required in storage of toiletries – communal areas must not have communal toiletries. Westhaven Nursing Home DS0000020915.V282857.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. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 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.V282857.R01.S.doc Version 5.1 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, 3, 4. The resident’s pre-admission nursing/personal care assessment documentation is comprehensive; ensuring that the skill mix of the workforce in the home can meet the resident’s identified care needs. EVIDENCE: The home’s Statement of Purpose has now been updated to reflect the new management structure of the home. 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. Since the last inspection the nursing pre admission document has been updated to include reference to the cognitive, or psychosocial care needs of the resident. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 9 The acting manager and the inspector discussed the importance of always ensuring that the home only admits the category of service user they are registered for, and how the new documentation should assist staff to only admit elderly physically frail. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 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. Resident’s individual health, personal and social care needs are clearly recorded, and provide care staff the sufficient information they need to meet the residents care needs. Medications are managed in accordance with good practice guidelines, thus helping to ensure the safety of all residents. 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 acting manager and senior nurses on a monthly basis. 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. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 11 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). The acting manager now completes regular medication and care plan auditing – this has been implemented since the previous inspection’s recommendations. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 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 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. EVIDENCE: Currently, various care staff organise the residents activities, the acting manager is advertising for an activities co-ordinator who will be responsible for the organisation of the residents activities. Residents in the home should be asked on admission about their past 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, hobbies, personal achievements, food likes and dislikes etc. This information should then be used to facilitate organised activities for the resident. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 13 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 bedrooms as they so wish. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 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): 18 The home’s policy and training programmes for POVA, and Whistle blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: The current information held at the care home regarding the Protection of Vulnerable Adults (POVA) has been updated since the previous inspection. The manager has obtained a copy of the latest Wirral Adult Protection policy and procedure, which is made available to all staff. On the day of the inspection there was evidence via the new staff induction booklet, that many of the staff in the home had undertaken some training on POVA protocols and the Whistle Blowing Policy. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 15 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, 26. The standard of decor within this home is good, with evidence of continuing improvements through maintenance and planning. The home presents 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, a move supported by many residents and staff. 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.V282857.R01.S.doc Version 5.1 Page 16 Resident’s bedrooms have been personalised with personal photographs and other memorabilia. 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. The acting manager told the inspector that a number of new, more appropriate chairs have been ordered and should be arriving at the home soon. The inspector was concerned to find toiletries left out in communal bathrooms. This practice must cease immediately as it presents a significant risk to any confused resident who may ingest these products. The acting manager assured the inspector that all such items would be removed without delay, and in future stored securely. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 17 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, 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 most staff. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 18 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, 36, 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. EVIDENCE: The acting manager is about to commence her registration process with the CSCI, and has many years experience at management level. 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 documented and actioned upon. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 19 All staff in the home have documented supervision six times per year, this ensures that all staff 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, or their nominated representative has failed to provide a monthly written report on the conduct of the home. This is a non-compliance from the previous inspection. The inspector was informed that since the previous inspection the asbestos in the ground floor cupboard has been removed by a recognised removal company, and the area made safe. 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. Westhaven Nursing Home DS0000020915.V282857.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 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 X 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 x 3 Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP12 Regulation 12 Requirement The registered person must ensure that suitable and sufficient activities are provided for all service users, and that any activity participated in is clearly documented in care files. The registered person must ensure that all actual and potential risks to the service users are identified and so far as practicable eliminated – refer to toiletries left out in communal areas – these must be removed with immediate effect. The registered person must ensure that all furniture and equipment provided at the care home is suitable for the needs of the service users. The registered person must appoint a registered manager – the acting manager must commence registration with the CSCI without delay. The registered person must complete Regulation 26 visits to the care home, and forward a copy of the monthly report to the CSCI. DS0000020915.V282857.R01.S.doc Timescale for action 30/04/06 2 OP13 13 16/02/06 3 OP20 16 & 23 30/04/06 4 OP31 8 30/04/06 5 OP37 26 30/04/06 Westhaven Nursing Home Version 5.1 Page 22 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 OP18 OP36 Good Practice Recommendations It is recommended that additional information and/or training be made available for all staff regarding the new Wirral Adult Protection policy and procedures. It is recommended that additional information be recorded on staff supervision files. Westhaven Nursing Home DS0000020915.V282857.R01.S.doc Version 5.1 Page 23 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.V282857.R01.S.doc Version 5.1 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. 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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