Inspection on 20/04/05 for Westholme

This inspection was carried out on 20th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westholme 29/11/07

Westholme 04/08/06

Westholme 14/09/05

Westholme 14/12/04

Westholme 01/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Westholme 55 Harestock Road Winchester SO22 6NT Lead Inspector Roy Bega Unannounced 20/04/2005 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Westholme Address 55 Harestock Road, Winchester, SO22 6NT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01962 881481 Hampshire County Council Mr Gregory More CRH 45 Category(ies) of DE(E) - 45 registration, with number of places Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 14/12/2004 Brief Description of the Service: Westholme is owned by Hampshire County Council providing personal care and accommodation for 45 older people who have been diagnosed as having dementia. The home is a two-storey building with 41 single bedrooms and 2 double. Five have en-suite toilet and wash hand basin facilities. There are gardens and parking to the front of the building and a large well maintained enclosed garden to the rear. The home is located on a main residential road on the outskirts of Winchester, and is accessible to local amenities and transport. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. Opportunity was taken to look around the home, view records and talk to staff. Due to residents high dependency needs, formal discussions with the majority was not possible. The inspector did however, join in with small group activities and observe relationships between residents and staff. No relatives visited the home during the inspection. The Unit Manager and a senior member of staff have been suspended from duty pending investigations under Hampshire County Council’s own disciplinary procedures. Mrs P Lee is the Acting Manager supported by a team of the home’s own and seconded Assistant Managers. Westholme is included in Hampshire County Council’s nursing strategy. In essence this means that over the next two years, an extension to provide 25 nursing beds is to be built on the current site. On completion of the new build, the current residential unit will then be refurbished. Ground clearing work to permit the building of the nursing unit has been completed. The project is three months behind. The initial start date was January 2005. Refurbishment of the current residential unit is planned to be completed December 2005. The number of residents is being reduced to 20 during the period of the new build and refurbishment. What the service does well: The home is well managed. The staff team have become more motivated, better trained and have good relationships with residents. Residents care plans are well documented in meeting their needs and wishes. Staff were observed to respect residents and explain aspects of care before carrying it out. Residents have a stimulating and varied life. There is a full informal activities programme provided by care staff who are willing to give up their own time on occasions. For example arranging a Victory in Europe party. Residents are also encouraged to maintain their independence as far is practicable and be part of the community. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 6 Whilst communication with residents was difficult due to their high dependency needs, it was evident that they are well cared for. They were well dressed and motivated. The inspector was invited to and did participate in some of the activities. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 standard(s) 3, 4 and 5. Due to the new build and refurbishment work, residents are no being admitted. Pre admission assessments therefore and trial visits do not apply. EVIDENCE: Records seen and discussions indicated that no new resident had been admitted subsequent to the previous inspection. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 standard(s) 7, 8, 9 and 10. Residents health, personal and social care needs are set out in an individual care plan. Residents are protected by the home’s policies and procedures for dealing with medicines. Residents are treated with respect and their right to privacy upheld. EVIDENCE: A sample of four care plans which covered all aspects of residents assessed physical, emotional and spiritual needs, wishes and interests were seen. They include risk assessments, Weight checks; Visits by health professionals and Night care needs. Daily record notes were up to date. There was evidence that care plans are reviewed monthly and signed by the staff member/s involved. Residents and/or relatives wishes to be/not to be included in reviews were recorded. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 10 It was acknowledged that more detailed information is required within care plans when relating to a resident requiring assistance. For example – “Will use a walking frame with prompting”. What sort of prompting? Verbal – What words are used? Observations, discussions and available training records indicated that staff have the skills and experience to deliver care effectively. The inspector observed on several occasions during the day staff sensitively defusing confrontational situations between residents and one directed towards the inspector. Staff were observed to relay to residents aspects of care before carrying it out. Staff were also observed to be courteous, respectful, ensuring residents dignity and privacy at all times. Medication records seen were up to date. Medication was stored appropriately. Staff were observed to distribute medication in a respectful manner. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 standard(s) 12. The home provides social, cultural, recreational and occupational activities suited to older persons. EVIDENCE: On arrival at the home, staff were engaged in stimulating activities with residents. For example, movement to music, dancing and floor based games. Returned letters sent to relatives requesting residents interests were seen. This is viewed as a positive contact for reference. The home has an activities co-ordinator who has received appropriate training for the post. Activities provided include, skittles, craft, word games, gardening, supervised walks in the garden, videos, board games, supervised community access, themed fish and chip suppers and excursions. Planned summer excursions include trips to - a local zoological park, a cruise on the Solent and visiting a stately garden. The inspector was informed with regards to a planned Victory in Europe Day party being arranged by staff who will be facilitating proceedings in their own time. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 12 Management and staff are to be commended with regards to the team work that has enabled this to develop. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 standard(s) 16. Residents and their relatives are assured that any complaint will be listened to, taken seriously and acted upon. EVIDENCE: The home’s complaints procedure was seen. It includes the stages and timescales for the process of managing complaints received. The inspector was advised that relatives are given copies. A complaints log comprising of single report sheets to promote confidentiality has been introduced. A sample of two complaint records were seen. It was noted that appropriate action had been taken. Residents are also able to voice their opinions/concerns through the media of resident meetings. Minutes of said meetings were seen. It was noted that concerns raised had been dealt with appropriately. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 standard(s) 19, 22, 23 and 24. There are maintenance and equipment issues within Westholme with regards to the four standards mentioned above. EVIDENCE: Westholme is included in Hampshire County Council’s nursing strategy. In essence this means that over the next two years, an extension to provide 25 nursing beds is to be built on the current site. On completion of the new build, the current residential unit will then be refurbished. Until work is completed the following will remain as requirements • • • • • • External and internal decoration. Replacing dining room floor. Up grading toilet/bathroom facilities. Damaged doors. Appropriate bed side lighting. Sluicing facilities. H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 15 Westholme • • • Appropriate radiator covers. Location of call bells. X 2 double electric sockets in service users bedrooms. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29. Staffing numbers and skill mix are appropriate to the assessed needs of residents. The home has a good recruitment policy and practices in place. EVIDENCE: The inspector was informed that it is planned to reduce the number of residents accommodated during building works to 20. At the time of this visit, 26 residents were in situ and 2 were in hospital. At the time of this visit the acting manager, 2 assistant managers, four care staff, two domestics a cook and two kitchen assistants were on duty. The available rota and discussions indicated the following Between the hours of 8 a. m. and 4 p.m. Monday to Friday the above formula applies. At weekends one assistant manager and four care staff are on duty plus ancillary staff. Between the hours of 4 p.m. and 10 p.m. one assistant manager and four care staff are on duty. Between the hours of 10 p.m. and 8 a.m. a sleep in assistant manager and 3 awake night staff. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 17 Subsequent to the previous inspection staff training records have been put in place. Information and records indicated the following courses have been completed – • A senior has completed the National Vocational Qualification in Care (NVQ) level 4. • 7 care staff have completed the NVQ in Care level 2. • 4 care staff are currently attending the NVQ level 2 • 2 care staff are booked to commence the NVQ level 2 in September 2005. Information and records seen indicated other training that has been completed subsequent to the previous inspection includes – • • • • • • Dementia care. Moving and handling. Adult Protection. Basic food hygiene. Emergency first aid. Fire Safety Precautions. Information and discussions indicated that the following courses are planned for the forthcoming six months • • • • Managing Challenging Behaviour. Infection Control. Care of the dying. Care of Substances Hazardous to Health. Management and staff are to be commended with regards to the positive attitude towards training. Hampshire County Council have a recruitment policy based on equal opportunities. A sample of 2 staff files were seen, both of which contained the required information. There have not been any staff recruited in the past six months. The inspector was informed however, that 5 new care staff from the European Union are commencing duties the second week of May and on 29 April, 6 local applicants are being interviewed. The inspector was advised that it is hoped that this will reduce the use of agency staff, therefore improve continuity of care. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36 and 37 Residents live in a home which is well run and managed with an ethos of being open and honest. EVIDENCE: Mrs P Lee (acting manager) has several years experience at a senior level. Mrs P Lee’s position as acting manager and other senior staffs secondments have been extended to the end of October 2005 to enable continuity within the home through the current transitional period. Discussions and observations indicated there are now clear lines of accountability within the home. Good relationships between all staff on duty was evident. Staff portrayed a strong loyalty towards their work and a positive attitude for training. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 19 Records and discussions indicated that structured staff supervision and personal development plans are in place. There is a commitment to equal opportunities. An example being training is available to all staff including those who work part time and at night. For the purpose of this inspection, records seen were well maintained and up to date. Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x 2 3 x 2 x x 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 Standard No 16 17 18 Score 3 x x 3 3 x x x 3 3 x Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 19 Regulation 23 (1 & 2) Requirement Timescale for action 28/02/06 2. OP 23 3. OP 24 Westholme is included in Hampshire County Council’s nursing strategy. Work outlined in Standard 19 is to be completed by the agreed timescale for the proposed project for the home. (February 2006) 23 (2b & Westholme is included in 2j ) Hampshire County Council’s nursing strategy. Work outlined in Standard 21 is to be completed by the agreed timescale for the proposed project for the home. (February 2006) 23 (1 & 2) Westholme is included in Hampshire County Council’s nursing strategy. Work outlined in Standard 21 is to be completed by the agreed timescale for the proposed project for the home. (February 2006) 28/02/06 28/02/06 Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 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. Refer to Standard Good Practice Recommendations Westholme H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 23 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 H54 S39597 Westholme V221702 200405.doc Version 1.20 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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