Inspection on 02/10/06 for Westhaven Nursing Home

This inspection was carried out on 2nd October 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 16/02/06

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 Key Unannounced Inspection 09:30 2nd October 2006 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.V300785.R01.S.doc Version 5.2 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.V300785.R01.S.doc Version 5.2 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.V300785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 34 nursing and 3 personal care within an overall total of 34. Date of last inspection 16th February 2006 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.V300785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted by CSCI Inspector Julie King, and took place over 5 hours. The nurse in charge, Mrs Maureen McDonough, accompanied the inspector 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. Some 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: 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.V300785.R01.S.doc Version 5.2 Page 6 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.V300785.R01.S.doc Version 5.2 Page 7 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): 3&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: Pre admission assessments provide a basic assessment of actual and potential needs of each prospective resident; thus allowing a care plan to be developed. However it was required that the pre admission assessment tool is utilised in more detail to ensure that all prospective resident’s needs are fully identified, therefore providing adequate information upon which to formulate a care plan. Multidisciplinary healthcare team (MDT) input is evident in resident’s care files, and include reference to NHS out-patient’s appointments, opticians, dentistry, and tissue viability nurse specialist (TVNS) input at the home when needed. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 8 As part of this site visit a number of residents were case-tracked. This involved following a resident from pre-admission up to date by examination of all assessments, care plans, family involvement, etc. Some of the care files examined, especially the newer admissions evidenced that not all the documentation contained within the care files was completed; this included colour photographic identification. Other documents not completed included the ‘ELDERS’ (depression and dependency rating scale); falls risk assessment, care plans not always specific and relatives communication records blank in some cases. However, most of the records seen were updated or could evidence recent updating. A recommendation will be issued to the registered manager to ensure that all care plans are individualized according to the assessed needs of each resident. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place for all residents. This provides staff with most of the information they need to meet the resident’s needs. 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.V300785.R01.S.doc Version 5.2 Page 10 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 were not in accordance with the National Minimum Standards (NMS) because of overstocking, gaps on medication administration records (MARs), inconsistent recording of drugs of potential abuse (only monitored for 13 days out of the previous 28), medications of more than six months old still in drugs trolley. A requirement will be issued to ensure future compliance with the national minimum standards. Residents spoken to said they were “happy living here”, and “the staff are lovely”. Staff appear to have a good rapport with residents and their relatives, and were observed sitting talking to some of the residents during the afternoon. Terminal care needs of each resident are met with assistance as needed from GPs, Macmillan Nurses, etc; and families are supported and enabled to spend as mush time as they wish with their relative at this time. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with the local community are good, and support and enrich the resident’s lives. Meals in Westhaven are good, offering choice and variety, and cater for resident’s special dietary needs. EVIDENCE: Residents in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in, such as outings, bingo and manicure therapy. On admission to the home the staff with help from a family member completes an initial care plan, which includes a social history as well as referring to hobbies, food likes and dislikes information, etc. This information is used to plan organised activities for the resident. Since the previous inspection, a designated activities co-ordinator has been appointed – a move that appears to be very welcomed by all residents. Visitors are allowed in the home at any reasonable time of day, residents may entertain their visitors in the communal lounges, or in their own bedroom. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 12 The gardens are accessible and tidy, and are an ideal setting for residents to sit with their relatives, especially in the summer months. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaint and adult protection policy and procedure was in place that helps ensure the safety and welfare of residents. EVIDENCE: The residents, relatives and staff can access complaint policies and procedures as and if necessary. The procedures includes information on ‘whistle-blowing’, in accordance with current Department of Health guidelines. The CSCI has not received any complaints about this service since the previous inspection. Most of the staff have, or are in the process of completing training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. Residents are enabled to exercise their right to vote, either via post or in person; and there is no religious or political persuasion in the home. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 14 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): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most resident’s rooms are personalized, providing residents with a homely place to live. 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 refurnished as needed. All communal bathrooms and toilets in the home provide privacy, and meet individual needs. The registered manager has now converted two bathrooms into a walk in shower, and mobile screens are available in all double rooms to ensure the privacy and dignity of the residents when personal care is being delivered. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 15 Resident’s bedrooms have been personalised with personal photographs and other memorabilia. Residents’ armchairs in the communal lower ground floor lounge identified during the previous inspection site visit as being too low have now been replaced, with more apparently on order. The inspector was concerned to find toiletries yet again left out in communal bathrooms. This is the second consecutive time that toiletries have been found in communal areas. This practice must cease immediately as it presents a significant risk to any confused resident who may ingest these products. The nurse in charge assured the inspector that all such items would be removed without delay, and in future stored securely. A requirement will be issued to this effect. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 16 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): 28,29. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the residents. EVIDENCE: A selection of staff personnel files were examined as part of the case-tracking process. Most files now contain all the required documents and records, but some are still in process of completion. CRB and POVA evidence was available, as were references, some training information, NVQ training, proof of identification and basic inductions. The home was able to evidence that most of the staff are in process of completing mandatory training (training that is required by law to do the job), and some resident specific training (such as care of the resident who has Parkinson’s Disease, etc.) had taken place, with more planned. Further evidence of training and supervision for all staff employed is required to fully meet these standards. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 17 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): 31,32,33,35,37,38. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Staff morale did not appear to be as high as previous, potentially leading to an increased staff turnover. EVIDENCE: The manager is now registered with the CSCI, and was clearly able to demonstrate her knowledge, competency and experience of running a care home. Since the previous site visit there have been a number of changes of staff at Westhaven, apparently leading to some discontentment amongst the staff. This will be discussed with the registered manager upon her return from annual leave. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 18 Some quality assurance is in place, and the home have achieved a nationally recognised award in this regard previously. A random selection of resident’s monies were examined and found to be well managed and correct with accurate records kept. Records were being managed in accordance with the Data Protection Act 1998, and required safety certificates were in date and valid. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 19 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 X X 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X 3 3 Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 20 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 OP19 Regulation 13 Requirement 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. Previous timescale of 16/02/06 not met. The registered person must ensure that all staff receive suitable and adequate training related to the work they perform, and this training is accurately documented on their personnel files. The registered person must ensure that good professional, working relationships are maintained between all staff. The registered person must ensure that all medications are managed in accordance with current good practice requirements and recommendations at all times. Timescale for action 02/10/06 2. OP28 18 31/12/06 3. OP32 12 31/12/06 4. OP9 13(2) 31/10/06 Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 21 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 OP36 OP4 Good Practice Recommendations It is recommended that additional information be recorded on staff supervision files. It is recommended that the pre-printed care planning documentation is utilised to its full benefit at all times for all residents. Westhaven Nursing Home DS0000020915.V300785.R01.S.doc Version 5.2 Page 22 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.V300785.R01.S.doc Version 5.2 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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