Inspection on 17/05/06 for Westholme

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westholme 05/03/08

Westholme 21/03/07

Westholme 25/01/06

Westholme 24/08/05

Westholme 20/12/04

Westholme 15/05/04

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

CARE HOMES FOR OLDER PEOPLE Westholme 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE Lead Inspector Lesley Plant Unannounced Inspection 10:00 17 & 23 May. 1 , 2 , 5 & 13th June 2006 th rd st nd th 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 Westholme DS0000009752.V290787.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. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westholme Address 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE 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) 01253 727114 Mrs Vivien Perry Care Home 31 Category(ies) of Dementia (31) registration, with number of places Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 31 service users in the category of Dementia (DE) 25th January 2006 Date of last inspection Brief Description of the Service: Westholme is registered to accommodate 31 service users with dementia, who are aged 65yrs or above. The property is large; with accommodation spread over three floors. Westholme is located near to the centre of St Annes, close to local services and amenities. The home is currently undergoing an extension and refurbishment programme, with the aim of improving the facilities. Mrs Perry is the registered provider and has owned the home for over 22 years. The home also has a manager registered with the Commission for Social Care Inspection. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the course of six visits to the home, the first day being unannounced. A fire safety officer was present for two of the inspection dates. Discussions took place with the owner of the home; the manager and several care staff. Records were viewed and a tour of the building also took place. Time was spent talking to and observing people living at the home. All the service users have various degrees of cognitive impairment therefore some conversations were brief and limited. Staff supported six service users to complete feedback forms for the inspection. Feedback forms were also received from six relatives, three GP’s and three other health professionals in contact with the home. Feedback was also gained from the viewing of questionnaires devised and distributed to relatives by the home. An inspection questionnaire completed by the manager provided additional information. The registered provider has appointed a manager of the home, who has recently registered with the Commission for Social Care Inspection. A CSCI pharmacy inspector carried out an inspection of the medication procedures in March 2006 and a separate report of this visit is available from the CSCI office. What the service does well: The daily records kept by staff are good and provide useful information for the rest of the team. Records of health care appointments are well maintained. Feedback from relatives was mainly positive, with a number commenting on improvements at the home and the personal qualities of the staff. One relative commented, “Staff amazing, genuine caring attention.” The physiotherapist, who visits the home to conduct group exercise sessions, gave positive feedback regarding the caring nature and helpfulness of staff. The visiting chiropodist also stated that the staff are good to work with and “always carry out any treatments or recommendations.” The processes and records regarding staff recruitment are generally good, with appropriate checks being made prior to new staff starting work. The registered manager is keen to make improvements to the service being provided at the home and has introduced a number of new systems and ways of working. The manager, deputy manager and care coordinator appear to work well together, forming a good management team. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Serious safety issues were raised with the registered provider. A number of these were satisfactorily addressed during the inspection period. The Lancashire Fire and Rescue Service had issued an enforcement notice regarding a number of essential fire safety requirements. The provider only rectified these following an extended period of notice, and several visits by the fire safety officer. Fire safety must remain a priority at the home. The lack of window opening restrictors posed a serious hazard to those living at Westholme. These were installed during the inspection period. Hazards posed by the ongoing building work must be continually risk assessed and minimised, as service users were not being adequately protected from danger during the inspection period. The registered provider must submit detailed plans to CSCI regarding the building alterations. This must include clear information of how this will be managed in such a way as to protect and provide a service to the individuals living at the home. The plans must show the designated use of each room. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 7 General maintenance is poor in some parts of the home. Observations included a broken window, broken furniture and badly hanging curtains. Regular maintenance checks and repairs need to take place. Issues, which seriously compromise the privacy and dignity of service users, were identified early in the inspection process. Bedrooms with glass panels in the door, the lack of accessible private space to receive visitors, limitations on access to bedrooms, an individual who was moved into another bedroom in order to receive increased care and the internal CCTV system are unacceptable. New doors were fitted during the inspection period and the CCTV cameras were removed. Privacy and dignity must be promoted at all times. No risk assessments were available regarding service users who require bed rails. These were swiftly put in place during the inspection period and must be regularly reviewed. Water must be monitored to ensure it is at a safe temperature. New systems have been introduced for the induction and supervision of staff. These need to be fully established and put in operation. Although medication procedures are much improved, there are still some outstanding areas to be addressed. Staff need specific training regarding dementia, which should be included as part of the core training programme. Day-to-day activities and stimulation could be improved by providing more one to one interaction. A number of policies are in need of review/updating, in order to support working practice at Westholme. The registered provider does not manage the home and is therefore required to carry out monthly monitoring visits and make a record of the findings. Copies of these monthly reports must be sent to the CSCI office. 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. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 8 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 Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 9 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 and 6 Quality in this outcome group is good. The assessment process helps to ensure that service users are only admitted to Westholme if their needs can be met. EVIDENCE: There have been no recent admissions to the home, as the number of residents is being restricted whilst the building and refurbishment programme takes place. The three files viewed showed that a social work assessment had taken place. Files also contained a nutritional assessment, moving and handling assessment and risk assessments addressing certain risks such as the laminated floor. There is a detailed assessment format in place, which provides opportunity to gather adequate information prior to admitting a new service user. The manager explained that she had visited an individual in hospital, got information from the social worker and also visited a neighbour; in order to make sure that the home had all the relevant assessment information. Prospective residents and their relatives are invited to visit the home prior to admission in order to view the facilities and meet the residents and staff. Westholme does not provide intermediate care. Westholme DS0000009752.V290787.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 and 10 Quality in this outcome group is adequate. Health and personal care needs are met. The privacy and dignity of service users has not been protected or promoted. EVIDENCE: The manager and staff are working hard to strengthen the care planning system and ensure that regular reviews take place. The five files viewed all showed that reviews are taking place, but this is not yet on a monthly basis for all service users. Each service user has a named key worker who is responsible for the review, and completes a monthly written overview. Staff keep good daily notes. Care plans now include a number of risk assessments. Examples viewed address such issues as challenging behaviour, guiding staff in the use of diversionary tactics to calm situations. Each person has a moving and handling assessment and risk assessments are in place regarding the laminate flooring. Although risk assessment within care plans has much improved no risk assessments were available regarding service users who require bed rails. This is essential as the use of bed rails can pose risk for individuals. Advice was given to the manager and risk assessments were swiftly put in place. These must be regularly reviewed as part of the care plan. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 11 Feedback from some relatives made reference to improvements with one stating, “**** (name of relative) has been much cleaner and more tidy recently and in her own clothes”. Mixed feedback was received from health professionals who visit Westholme, with the Fylde Primary Care Trust raising concerns regarding the prevention of pressure sores. This appears to have been addressed and more pressure relief cushions have been obtained. At the time of the inspection visits there was one service user with a pressure sore who was receiving input from a district nurse. The staff spoken to all confirmed that they had received guidance in skin care and pressure relief. A record of turning and fluids given was being kept for one individual who was ill and in bed. The manager must continue to monitor this aspect of care. The physiotherapist, who visits the home to conduct group exercise sessions, gave positive feedback regarding the caring nature and helpfulness of staff. The visiting chiropodist also stated that the staff are good to work with and “always carry out any treatments or recommendations.” The three GP’s who completed comment cards all responded that they are satisfied with the overall care at the home. Nutritional assessments are in place and the files viewed showed that weight is monitored and recorded. Records are maintained of all GP visits. A CSCI pharmacy inspector had carried out an inspection of the medication procedures in March 2006, making a number of requirements and recommendations for action. Significant improvements have been made since this pharmacy inspection. The senior staff member with lead responsibility for medication procedures has worked hard to bring about changes to working practices. Feedback from the pharmacist who dispenses medication to the home also confirmed that improvements have been made, stating that the home has needed extra support in the past but that there have been no recent issues. Training certificates were viewed for all senior staff involved in administering medication. Medication storage facilities have been improved and made more secure. The storeroom door now has a self-locking mechanism. Medications requiring cold storage are kept in a dedicated fridge. Records show that the temperature is regularly monitored. Handwritten medication administration record (MAR) sheets are now checked and signed by two staff, although one of those viewed had not been dated. The two computer generated MAR sheets viewed, were dated, included the number of tablets received and were signed. Controlled drugs are now safely and securely stored and the controlled drugs register is being completed appropriately. Each MAR sheet carries a photograph of the individual. Staff monitor any changes and seek advice as necessary. A service user had been discharged from hospital, where her medication had been changed. The GP had advised that this individual should remain on this medication, however Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 12 staff were concerned re her increased drowsiness and were seeking further advice from the GP. A weekly audit check has been introduced, which will help to ensure that all staff follow the agreed procedures. This includes a check of stock and a check that administration records are being correctly completed. At present the senior staff member with lead responsibility carries out these checks. The manager is advised to spread this responsibility within the management team and also to ensure that other senior staff are fully capable of ordering medication etc in the absence of the lead person. The manager and deputy manager should use the audit checks as one means of monitoring the competence of staff who are handling medication. The use of the key code to explain the non-administration of medication still needs some clarification to ensure consistency. Details of “when required” medication is now included within the care plan, however this still needs improving, to include the exact circumstances particular to the individual, of when medication should be administered. For example, how an individual would indicate if in pain and required pain relief medication. The CSCI pharmacist inspection had recommended that all medication not contained within the monitored dosage system should be dated upon opening and that prescriptions should be seen and checked prior to the pharmacist dispensing. These procedures have not yet been implemented. Issues, which seriously compromise the privacy and dignity of service users, were identified early in the inspection process. Bedrooms with glass panels in the door, the lack of accessible private space to receive visitors, limitations on access to bedrooms, an individual who was moved into another bedroom in order to receive increased care and the internal CCTV system, all indicate that privacy and dignity are not promoted or upheld at Westholme. The inspection was carried out during six visits to the home and during this period certain problems were addressed, in that the CCTV cameras were removed and the bedroom doors renewed. The gates on the stairs need to be reviewed, in order to balance the need for safety with the need for service users to have access to their bedroom. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 13 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 and 15 Quality in this outcome group is adequate. The activity programme, although improved, does not provide enough one to one time for each individual. The current dining area is not a pleasant place to eat meals. EVIDENCE: Questionnaires designed and distributed by the manager show that some relatives feel that the provision of activities has improved. The activity plan was viewed, showing physiotherapy exercises, hairdressing and trips to a hotel. Games equipment, such as for playing boules and skittles is provided. Staff were observed giving manicures to the ladies. The staff spoken to said that they are able to take individuals out and that they are able to spend one to one time with people at the home. During the inspection staff were seen working hard carrying out the necessary routine tasks, however there was little evidence of staff spending individual time with service users. The daily notes kept by staff often stated “watched TV”. However, it was observed that although the TV is on, service users are not necessarily watching it or gaining any pleasure from the TV. The manager should continue to monitor the activities programme and look for ways for service users to receive one to one attention, other than for practical care. A staff member has been given the responsibility of reviewing and organising the activities programme. One relative stated, “would like more one to one care and company given, pleased to see they have increased the outings.” Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 14 Feedback from relatives confirmed that visitors are made welcome at Westholme, although the lack of an accessible private room to chat was also raised. It is anticipated that the planned increase in social/lounge space will partly resolve this problem. The service users at Westholme all have a diagnosis of dementia resulting in various degrees of cognitive impairment. A relative will usually take responsibility for financial affairs and make any necessary decisions on their behalf. Feedback from relatives indicates that they are kept informed of important matters. Due to the building work, there are temporary dining arrangements in place, as the current temporary dining room cannot accommodate all the service users at one time. This room does not provide a pleasant or relaxed environment, as access to the rear outdoor area and also the office is via this small room. The manager and staff appear to be doing their best during difficult circumstances. Meals are staggered over an extended period, with staff keeping a record of who has had an early or later meal. There is a two weekly menu in place. There is a cook on duty each day, who knows the individual preferences of each person at the home. Nutritional assessments now take place and risk assessments regarding eating were viewed on case files. The staff spoken to showed a good understanding of individual needs regarding meals. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 15 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 and 18 Quality in this outcome group is good. Arrangements for handling complaints are in place. Recruitment procedures and written guidance promote the protection of those living at the home. EVIDENCE: There have been no complaints since the last inspection. The complaints procedure and accompanying complaints form were viewed. The complaints procedure gives a clear timeframe within which concerns would be responded to. Feedback questionnaires sent to relatives were viewed, giving opportunity for people to raise concerns. The manager has a copy of the No Secrets in Lancashire guidance and is aware of the correct vulnerable adults procedures. However the Westholme policies relating to protection are still in need of review and amendment. The current whistle blowing policy, in particular gives misleading information. The manager confirmed that the registered provider has arranged for an external consultant to review these policies. Recruitment files show that appropriate checks are undertaken prior to staff being employed at the home. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 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 and 26 Quality in this outcome group is poor. Poor maintenance, poor fire safety precautions and the ongoing building work are potentially hazardous to service users. The home is clean. EVIDENCE: A tour of the building identified a number of serious concerns and potential hazards. Building work is taking place and on the first day of the inspection there were inadequate procedures in place to prevent service users accessing hazardous areas. Windows in a number of rooms above ground floor level could open dangerously wide. An immediate requirement notice was issued, which was promptly responded to, with window opening restrictors being fitted the following day. Other hazards included an electric socket extension cable in an ensuite toilet room, a broken window on a stairway and a broken light fitting. Several areas of the home were poorly maintained with a number of bedrooms having curtains requiring attention and broken furniture. Regular maintenance and hazard inspections must take place and any problems be quickly addressed. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 17 The registered provider was informed that the room overlooking the office/conservatory is not appropriate for use as a bedroom and that bedrooms should have lights/light switches next to the bed. CCTV cameras installed in lounge areas and corridors are unacceptable and these were removed during the inspection period. Serious safety issues had been identified by the Lancashire Fire and Rescue Service, with a 28 day Enforcement Notice being issued. This was not complied with. The issues identified were only dealt with following an extension to the enforcement notice and several visits from the fire safety officer. The registered providers’ response to the enforcement notice raises serious concerns regarding the commitment to provide and maintain a safe environment for service users. The registered provider must submit detailed plans to CSCI regarding the building alterations. This must include clear information of how this will be managed in such a way as to protect and provide a service to the individuals living at the home. The plans must show the designated use of each room. The home employs staff with specific responsibility for laundry and domestic tasks. There are plans to renew the laundry facilities. One bedroom had an offensive odour, which needs remedying. It is understood that new flooring would be fitted in this room. Staff were observed following infection control procedures by wearing protective clothing for certain tasks. Feedback from one relative included, “ there used to be a bad smell when entering, however those carpets have been removed and it’s much improved.” Westholme DS0000009752.V290787.R01.S.doc Version 5.1 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 and 30 Quality in this outcome group is adequate. The home is staffed appropriately and NVQ training is promoted, providing opportunity for staff to develop further skills in their work. Recruitment procedures promote the protection of service users. A more thorough induction process and training in dementia would increase staff competence. EVIDENCE: There are currently 20 service users living at Westholme. The staff rotas viewed show two or three staff during the night and three or four staff on duty during the day. The kitchen, laundry, domestic and management staff are in addition to these numbers. Most mornings there are four care staff on duty plus the manager and deputy manager. Feedback about the personal qualities of staff was positive, with one relative commenting, “staff amazing, genuine caring attention.” There are 16 staff plus the manager; this includes day and night staff. Two staff have achieved NVQ level 2 and another, the deputy has achieved NVQ level 3. Seven of the team are working towards NVQ awards. The manager, a qualified NVQ assessor, is acting as assessor for five of these staff. The deputy is undertaking the registered managers award, including NVQ units, which will allow her to carry out NVQ assessments. This will spread the task and allow staff to progress more quickly through the award. The three staff recruitment files viewed showed that good procedures are in place. Two references are obtained, an application form completed and a criminal records bureau disclosure obtained. Each file also contained a record Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 19 of the interview, contract of employment and job specification. Following previous advice and a reminder issued during this inspection, a record of any discussion regarding employing a staff member with a conviction is maintained. The provision of staff training has improved since the last inspection. A training matrix for the staff team is now in place. Staff who have completed core training such as fire safety, infection control, vulnerable adults, food hygiene, first aid, moving and handling and health and safety are clearly identified. The majority of staff have attended these courses, although the gaps do need addressing. Good links have been established with a training provider, in relation to this core training. New staff receive an induction file containing the Skills for Care Induction standards. This new induction process is not yet fully established and the next inspection should see completed induction records. In addition to meeting the Skills for Care Induction standards there should also be a programme of introduction to the home and work setting, carried out by senior staff. Old induction records are available for some staff, who completed a swift introduction to the home. This could be used as a guide, with more time being spent on key areas, during the first few weeks at work. Three staff spoken to had not undertaken any specialist dementia training, which should be addressed. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 20 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, 33, 35, 36 and 38 Quality in this outcome group is poor. The new management team are introducing positive changes, which should improve the quality of life for service users. Health and safety at Westholme has not been promoted, resulting in potential danger for people living at the home. EVIDENCE: The manager has been in post for six months and is registered with the CSCI. The manager is experienced in the field of social care and is qualified to level 4 NVQ. There is also a deputy manager and a care coordinator, plus senior care assistants. The care staff spoken to are aware of the lines of accountability and know who to go to should advice be needed. The manager has made improvements in several areas, introducing new systems and procedures. The next few months need to see these systems being operated and reflected in improved positive outcomes for the residents at the home. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 21 The home has designed questionnaires and distributed these to relatives, in order to gain feedback about the quality of the service provided. The responses show that generally relatives feel that improvements have been made. This process should be continued, as many people living at Westholme are unable to voice their views personally. The current building work, if completed satisfactorily should provide an improved living environment for service users. The registered provider does not manage the home and is therefore required to carry out monthly monitoring visits and make a record of the findings. Copies of these monthly reports must be sent to the CSCI office. For the majority of people living at the home, a relative will take responsibility for finances. A personal allowance record sheet is kept on behalf of each person living at the home. This shows expenditure such as hairdressing costs, which would then be paid by the relative on behalf of the individual. The registered provider, Mrs Perry acts as appointee for two service users and personal spending money for these people is kept at the home. The records for these individuals were viewed and the record of money held balanced with the cash held. A safe is available, although the home does not normally keep valuables on behalf of service users, this could be provided if required. The manager was advised to keep the record of the safe contents in a separate location, other than in the safe. The staff spoken to confirmed that a supervision/appraisal system is being introduced. One staff member in post for five months had had two such meetings and one staff member in post for three months had had one such meeting. Staff were aware that the frequency of supervisions was set to increase. New staff work alongside a more experienced member of the team and this is highlighted on staff rotas. The management team should be providing supervision sessions at least six times each year. Senior staff including, the deputy manager regularly work alongside staff and can therefore influence work practice. The current position of the office and the managers’ focus on administrative work limits the managers’ input in this area. Once all the new systems are in place, the manager aims to spend more time working alongside care staff, guiding, mentoring and promoting good standards. The core-training programme includes training in safe working practices and records show that most staff have completed these courses. Any gaps need to be addressed. The pre inspection questionnaire completed by the manager confirmed certain safety checks taking place such as the checking of the electrical wiring at the home, the checking of electrical appliances and legionella testing. On the first day of the inspection windows in rooms above ground floor level were able to be opened dangerously wide. An immediate requirement notice was issued, which was promptly responded to, with window opening restrictors being fitted the following day. . Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 22 Water outlets are fitted with thermostatic regulators, however the regular testing and recording of water temperatures must still take place. The lift maintenance certificate was not available for the inspection. The registered provider must provide a copy of this to the CSCI. As reported in the evidence for standard 19 of this report, the registered provider had failed to comply with the Fire Precautions (Workplace) Regulations. This breach posed serious health and safety hazards for those people living and working at Westholme. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 23 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 2 x 1 Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP7 OP18 Regulation 13 13 Requirement The use of bed rails must be risk assessed and regularly reviewed. The abuse policy must be reviewed to incorporate the correct reporting and recording protocols as stated in ‘No Secrets’ (Not met from previous inspection) The privacy and dignity of service users must be respected. CCTV must not be used in such a way as to intrude on the daily life of service users. Regular maintenance and hazard inspections must take place and any problems be quickly addressed. The registered provider must submit detailed plans to CSCI regarding the building alterations. The registered provider must comply with the requirements of the Lancashire Fire and Rescue Service. The registered provider must DS0000009752.V290787.R01.S.doc Timescale for action 31/07/06 31/07/06 3 4 5 OP10 OP10 OP19 12 12 23 13/06/06 13/06/06 31/07/06 6 OP19 23 06/07/06 7 OP19 23 13/06/06 8 OP33 26 31/07/06 Page 25 Westholme Version 5.1 9 10 11 OP38 OP38 OP38 13 13 13 carry out monthly monitoring visits and send reports to CSCI Water temperatures must be regularly tested and records maintained. A copy of the most recent lift maintenance certificate must be sent to CSCI. Window restrictors must remain fitted and be regularly checked. 31/07/06 06/07/06 13/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP9 OP9 OP9 OP10 OP12 Good Practice Recommendations All medication not contained in the monitored dosage system should be dated upon opening. All prescriptions should be seen and checked prior to the pharmacist dispensing. ‘When required medication, although included within the care plan, should contain more specific detail. The gates on the stairs need to be reviewed, in order to balance the need for safety with the need for service users to have access to their bedroom. The manager should continue to monitor the activities programme and look for ways for service users to receive one to one attention, other than for practical care. The dining space does not provide a pleasant or relaxed area for eating meals and priority should be given to remedying this situation. The room overlooking the office/conservatory is not appropriate for use as a bedroom. Bedrooms should have lights/light switches next to the bed. Progress with NVQ training should be monitored; in order to achieve 50 qualified staff. All staff should complete the core-training programme, DS0000009752.V290787.R01.S.doc Version 5.1 Page 26 6 8 9 10 11 OP15 OP19 OP19 OP28 OP30 Westholme 12 13 OP30 OP36 which should include dementia training. Induction training should meet Skills for Care standards. All care staff should receive supervision at least six times a year. Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Westholme DS0000009752.V290787.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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