Inspection on 20/12/05 for Westholme

This inspection was carried out on 20th December 2005.

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

The inspector 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 21/08/07

Westholme 03/10/06

Westholme 25/05/05

Westholme 01/02/05

Westholme 27/07/04

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

CARE HOMES FOR OLDER PEOPLE Westholme Thornhill Road Upper Wortley Leeds LS12 4LL Lead Inspector Chris Levi Unannounced Inspection 20th December 2005 09:15 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 DS0000033302.V261772.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westholme Address Thornhill Road Upper Wortley Leeds LS12 4LL 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) 0113 2638203 0113 2638203 Leeds City Council Department of Social Services Ms Maureen O`Malley Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (1) of places Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user under the age of 50 years is eligible for the PD placement 25th May 2005 Date of last inspection Brief Description of the Service: Westholme is a care home owned by Leeds City Council and managed by Mrs. O,Malley. The home provides personal care and support to forty older people a number of who visit the home for respite services. Since the last inspection, the providers have applied to the Commission for Social Care Inspection to vary the current registration category to include one place for a person under the age of sixty five years with physical disabilities. This person must not be under the age of 50 years. This has now been agreed with the CSCI. The home is situated in Wortley a suburb of Leeds. The home is on two floors and has a passenger lift to the second floor. Gardens surround the home and there is a small car parking area. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 9.15am finishing at 2.15pm. The person in charge at the time of the inspection was the manager Mrs M. O’Malley. Most of the day was spent talking to service users, visitors and staff about living and working at Westholme. People living at the home liked to be referred to as residents in the inspection report. Some documents were inspected including, care plans, minutes of meetings with residents and staff and records of complaints. The inspector looked around part of the building. The atmosphere within the home was open, friendly and welcoming. The home was decorated with Christmas trimming and looked very festive. The person in charge was given feedback about the inspection findings at the end of the inspection. A list of requirements identified from this inspection can be found at the end of this report. What the service does well: Westholme is a well run home that provides good standards of care to residents. Staff continue to work hard to ensure the residents who live at Westholme feel welcomed, safe, and confident that they will give the necessary help with their care, in a professional and friendly manner. Residents are encouraged to maintain interests outside the home, and staff assist them where possible. One resident told the inspector he was taking the home manager out shopping, he was busy preparing for Christmas, and so the inspection could wait! Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 6 Residents are consulted about what is happening at the home on a regular basis. Visitors said they are always made welcome, never made to feel a nuisance, and enjoy visiting the home. One said, “ The staff always let me know what’s happening with my mum.” The management of resident’s personal allowances demonstrated good practice. The procedure for recruiting staff is very thorough, to ensure they are suitable to care for vulnerable older people. What has improved since the last inspection? What they could do better: The kitchen is in a poor state of repair. Remedial work must be undertaken by the providers to ensure a safe working environment. 2 bedroom carpets require replacement or alternative floor covering. The providers must introduce an effective annual quality monitoring system. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 7 Mrs O’Malley must prioritise achieving a formal management qualification. Lifestyle plans must include specific care plans where a risk to a resident has been identified. 50 of care staff must achieve an NVQ level 2 qualification. 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 DS0000033302.V261772.R01.S.doc Version 5.0 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 DS0000033302.V261772.R01.S.doc Version 5.0 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): 1,2,3,6. People who use the service are able to access clear and accurate information to help then decide whether or not they wish to live in the home. Effective systems are in place to assess service user needs before admission. Residents receive documentation identifying their rights and responsibilities and charges made for the services received. The home does not provide intermediate care services. EVIDENCE: Written information about services provided at Westholme is clearly displayed for residents and visitors to read. The information was last reviewed in March 2005, but appeared up to date. Two pre admission assessments were looked at. Both gave relevant information about the residents needs. This enabled staff to decide what care and support the resident would require when moving to Westholme. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 10 All permanent residents are given a written licence to occupy. This is a legal contract that identifies the rights and responsibilities of the resident and the home. It is positive to note that these documents are now reviewed on an annual basis to reflect changes in the annual feeds charged by the providers. Westholme has a number of regular short stay residents. It is recommended that respite residents should also be given contacts. Westholme does not provide intermediate care services. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 11 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): 7,8,10 Staff at Westholme meet the care and health needs of residents. It was observed and confirmed by a number of residents, and visitors, that they are treated with dignity and respect by staff at Westholme. EVIDENCE: The standard of information in residents care plans continues to improve. It is comprehensive and relevant, enabling staff to provide effective care and support to individual residents. There was evidence of resident or relative’s signature agreeing to plans of care. These plans are reviewed on a monthly basis to maintain and promote the health and well being of residents. When a risk to the residents well being is identified, a detailed risk assessment and specific plan of care must be in place. Examples identified, include a resident with poor mobility and diabetes. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 12 There was evidence that resident’s falls are recorded and analysed monthly. As a result, one resident had agreed to move to a ground floor room to reduce the distance she had to walk to the dining room and lounge. Community health professionals visit the home to provide for residents health needs, where a need has been identified. Both care plans looked at had evidence of visits by GPs, and district nurses. Talking to residents during the visit their comments included “ the staff are so kind”. “ They do a marvellous job.” “ Nothing is too much trouble to them.” Staff were observed supporting residents in a discreet way, and with respect. They know the residents well, and enjoy good social banter, which the residents like. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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. Residents are given opportunities to choose how they spend their day. Residents are supported and enabled to maintain contact with family, friends and the local community. EVIDENCE: Residents said they were happy living at Westholme. Comments included “ cannot stop and chat, the manager is taking me Christmas shopping, but I like it here.” “ I was up late last night at the party, I really enjoyed it.” One resident had just had her 100th birthday with a big family party at the home. She said, “ it was a lovely day, the staff here are wonderful.” There had been numerous shopping trips for those residents who wanted to do Christmas shopping. For those unable to go out, staff had made purchases on their behalf. Residents had decided the Christmas menus as part of the regular consultation with the manager. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 14 In discussion with visitors they were very positive about the standards of care at the home. One said, “ They always keep me informed of what’s happening with my mum, I really appreciate that.” Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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): 16,18. The home provides clear information on how to make a complaint about the service. It includes reference to the Commission for Social Care Inspection if people want to take a complaint outside the home. Systems are in place to protect residents from abuse. EVIDENCE: Posters are clearly displayed throughout the home about how to make a complaint. One complaint had been recorded since the last inspection. There was evidence it had been correctly recorded, investigated and the complainant was satisfied with the outcome. Staff undertake training in recognising and reporting any allegations of abuse. Staff understood the term whistle blowing and who to talk to if they had concerns. It is positive to note that staff in charge of the home now have contact numbers for senior managers in the event of “out of hours incidents.” Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26. Systems are in place to ensure the environment is safe, but also welcoming and comfortable. Residents move freely about the home, making decision about where they spend their day. EVIDENCE: Communal areas at Westholme have been refurbished. The main dining room looks much lighter and brighter and the flooring is more suitable. Residents had chosen the wallpaper and were pleased with the results. The remedial work required in the kitchen identified in the last report, remains outstanding. The kitchen is now in a poor state of repair, with tiles coming off the walls and the kitchen floor lifting in areas. However, the manager stated the providers have identified this work will be undertaken early in the New Year. The home was clean and free from odour in the communal areas. A number of bedrooms require new carpets or alternative floor covering. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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): 28,29. The providers, Leeds City Council Social Service Department, have a robust interview process when recruiting staff. The home has yet to achieve 50 of care staff with NVQ level 2. EVIDENCE: Leeds Social Service department has recently changed the recruitment procedure to include a satisfactory CRB report, before the employee commences work at the home. The department has a thorough recruitment procedure. Eight of nineteen care staff have achieved NVQ level2 or 3. This is not quite the 50 total required. However, there was evidence that a number of staff have almost completed the award. The home has three NVQ assessors, this will result in staff completing the award without being dependant on external assessors. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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): 31,33,35. Westholme is a well managed home where residents and staff are consulted about the service. The manager has yet to achieve a management qualification. There was no evidence that an annual, formal quality management review of services takes place. Robust systems are in place to ensure that residents monies held at the home are secure, but accessible when needed. EVIDENCE: Mrs O’Malley has many years experience of managing residential care services for older people. Both resident’s visitor’s and staff said she is approachable and has a very open and consultative style of management. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 19 Since the last inspection the Commission has registered Mrs O’Malley as the manager of Westholme, on condition that she achieve a management qualification by February 2006. Due to changes in the award Mrs O’Malley will not achieve the target date. A senior manager was asked to write to the inspector with details as to how this requirement would be prioritised. The home manager was unable to provide evidence of an effective quality monitoring review of services. There was evidence of regular meetings for both residents and staff and regulation 26 monthly visits by a senior manager. The home has a robust procedure for managing resident’s money held at the home. Residents have a locked drawer facility in their own rooms. However, some residents and relatives prefer that the home hold their personal money. The systems for managing this facility were looked at in detail. Two residents personal allowance money was checked. One had an inaccurate balance. It was rectified with the inspector, as it was an addition error. The home has a visiting administrator who undertakes routine weekly audits. The system is such that a resident can, at anytime of day, access money held on their behalf. This is good practice. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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 3 3 x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 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 2 3 2 x 3 x X X Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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 OP7 Regulation 12 Requirement Lifestyle plans must include a specific risk assessment and care plan for residents with poor mobility and diabetes. The kitchen floor must be replaced in addition to the replacement of bins and trolleys used by the kitchen staff. A risk assessment must be undertaken for the hot trolley. (identified in the previous report) 50 of care staff must achieve NVQ level 2. (identified in the previous report) The manager must complete NVQlevel4 (identified in previous report) This is a condition of her registration with the CSCI. The providers must implement a quality monitoring system. Timescale for action 01/02/06 2. OP15 13 30/03/06 3. 4. OP28 OP31 18 9 30/03/05 30/06/06 5 OP33 24 30/03/06 Westholme DS0000033302.V261772.R01.S.doc Version 5.0 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 OP2 Good Practice Recommendations Respite residents should be issued with contracts. Westholme DS0000033302.V261772.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000033302.V261772.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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