Inspection on 24/08/05 for Westholme

This inspection was carried out on 24th August 2005.

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 17/05/06

Westholme 25/01/06

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 Lillian McMullen Unannounced 24 August 2005 th 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 F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westholme Address 24-28 Victoria Road St Annes On Sea Lancashire FY8 1LE 01253 727114 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) Mrs Vivien Perry Mrs Lorraine Mynott Care home only 31 Category(ies) of DE Dementia (31) registration, with number of places Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate 31 service users in the category of Dementia (DE). Date of last inspection 20th December 2004 Brief Description of the Service: Westholme is registered to accommodate 31 service users who are suffering from a dementing illness who are aged 65yrs and above. The property is large and spacious and allows for service users freedom of movement. Mrs Perry is the registered provider she has owned the home for 22 years. The registered manager is responsible for the day-to-day management of the home and is developing the service to ensure the staff can meet the demands of the service users. The accommodation is on 3 floors, and is currentley undergoing a total refurbishment in order to improve the facilities. All service users have their personal care needs catered for by the staff, any medical treatment is provided by the G.P. or the district nursing staff. Specialised services are commissioned as required to meet individual need. Chiropody, ophthalmic and dental treatment are arranged by these professionals visiting the home. The hairdresser visits Westholme on a weekly basis. Visitors are welcome at any time, service users are encouraged to be as active and socially stimulated as much as possible. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by two inspectors. The inspection started at 10.00am and took place over 6 hours. The Inspectors spoke to four staff members, two residents, three relatives and the registered manager. Part of the inspection was spent on looking at care documentation and the recruitment procedures. What the service does well: What has improved since the last inspection? A refurbishment programme has commenced which will involve all accommodation being upgraded. Three bedrooms have been completed and work has commenced on three others. Once the work is completed all bedrooms will have en suite facilities. The refurbishment programme includes the installation of a passenger lift; a kitchen re fit, a new laundry and all communal rooms will be upgraded. Since the previous inspection an administrator has been employed who will have the responsibility to ensure good recording systems are in place. It is intended that the administrator will be part of the management team and support the registered manager in the management of staff development and the general day-to-day management of the home. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 6 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. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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 F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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 The assessment process ensures that all residents are admitted following a needs assessment. EVIDENCE: The file of three residents was examined. As Westhome cares for residents that are suffering from a dementing illness it is usual practice for a social worker to be involved in referring prospective residents. The inspectors found evidence on file of social work assessments and details of the resident’s needs and abilities. The registered manager admits residents to Westhome Care Home following an assessment of current needs and requirements. As observed at the time of inspection, the assessment information gained by the registered manager is brief and in some cases contains only one word responses. Whilst it is acknowledged that it is difficult to gain good quality information from the prospective resident every effort should be made to Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 9 acquire as much information as possible from any available source, which should include relatives/present carers. All 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 F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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 standard(s) 7,8 and 9 Care plans are complicated, making them difficult to follow. Care notes are brief and do not provide comprehensive information in relation to how the health needs of the residents are met. EVIDENCE: The care planning documentation is lengthy and complicated which make care plans difficult to follow. The current system incorporates a number of documents that all require cross-referencing in order to establish the needs of the individual. Presently care plans focus on the physical needs with little or no mention of the individuals, social, religious or cultural needs. The registered manager was asked to review the present system to ensure care plans are working documents and take into account the total needs of each individual resident. The inspectors provided some advice on what constitutes a good care plan, and document not only what the individual needs are but also how the needs are to be met together with expected outcomes. Risk assessments in relation to falls and moving and handling are in place and it was pleasing to note that the home has been involved with the falls coordinator from the Primary Care Trust to develop practices that reduce the Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 11 number of falls sustained by residents. However additional risk assessments are required to be in place especially in relation to the management of challenging behaviour. Staff should also be trained in the management of challenging behaviour in order that they understand what could trigger difficult behaviour and diversion techniques in order that challenging behaviour is not managed primarily by medication. The inspectors advised that risk assessment should be an integral part of the care plan with all potential hazards identified with indicators that should be in place to minimise the risk of harm to staff and residents. Consideration could also be given to introducing ‘Antecedent, Behaviour, Consequence’ (ABC) charts in respect of residents who display challenging behaviour. This process could assist staff to establish if a pattern of challenging behaviour is the result of a specific or multiple stimulus (or lack of appropriate stimulus) and if the stimulus could be reduced or modified. Staff would clearly need to observe closely, record accurately and remain objective and impartial. Daily diary notes were examined and these were found to be completed three times a day. However some entries were found to be brief and repetitive. As these daily notes provide a log of the individuals well being greater detail must be documented and entries such as ‘ no problems today’ should be avoided. It was also of concern that details of doctor’s visits were brief and in many cases did not provide details of any diagnoses or advice provided by the doctor. Therefore it is difficult for staff to provide a consistency of care as the lack of formal written records relies totally on verbal communication between staff, which can be unreliable, resulting in residents receiving a inconsistent care service. In addition the terminology used on some of the care records is unacceptable, the terms ‘aggressive’ and ‘bully’ should not be used. Staff should be instructed on how to complete professional records and adopt the fact and opinion rule. Whilst the inspectors feel that improvements could be made in the recording and care planning this does not impact on the, relative’s perception of the care provided. All relatives spoken to say they were satisfied with how the residents were cared for. One relative said, “ the staff are marvellous, I don’t know how they cope”. Another relative commented that she visits each month but that her Aunt visits every other day and said, “my aunt is really on the ball and would soon say if she was not satisfied”. The wife of a resident was very satisfied and said, “I am informed of everything, the manager rings me if my husband is not well or if there are any changes at all”. All relatives stated that they are free to visit whenever they wish. The standard associated with medication was not fully assessed at this inspection, however the inspectors examined a number of medication administration records and found them to be correctly completed. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Meals are well prepared, nutritious and varied to meet the tastes and preferences of the residents. EVIDENCE: From observation and discussion with the cook evidence was found to confirm that the meals served were nutritionally balanced with a varied menu provided. The cook confirmed that the budget was sufficient to maintain a consistently good standard. The inspector noted good food stocks with plenty of fresh produce. Staff were seen assisting residents with eating and was pleased to see this task was carried out in a unhurried and respectful way. However plastic picnic cups were being used at the dining table at lunchtime, which should be replaced for suitable crockery. The inspector also noted that deserts were served prior to residents finishing their main meal, which as observed by the inspector resulted in one resident mixing her desert with the gravy from her main meal. Staff should be asked to wait until residents have finished their main meal before serving desert. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 13 The kitchen facilities are poor and are in need, of redecoration and new equipment. A dishwasher is urgently required and repairs are required to the deep fat fryer. It is acknowledged that the kitchen will have a total refit as part of the refurbishment programme, however priority should be given to improving the present condition of this area. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the above standards were assessed at this inspection. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 The home is maintained to a satisfactory standard and the refurbishment programme is not impacting on the resident’s safety or wellbeing. EVIDENCE: The home is maintained to a satisfactory standard and the refurbishment programme appears to be being managed successfully. Three bedrooms have undergone a complete refurbishment. At the time of the inspection work was being carried to refurbish a further three bedrooms. Once the work is completed all bedrooms will have en suite facilities. The refurbishment programme includes the installation of a passenger lift; a kitchen re fit, a new laundry and all communal rooms will be upgraded. It was pleasing to note that a new call bell system is to be installed with work on this project to commence this week. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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 and 29 Staffing levels are satisfactory to meet the needs of the residents. The policies and procedures for the recruitment of staff need some tightening to provide safeguards for the protection of residents. EVIDENCE: At the time of the inspection staffing levels were satisfactory to meet the needs of the residents with four care staff working on the floor to care for 24 residents. Relatives spoken to said that, the staff are friendly and helpful and even though busy did respond to the needs of the residents. The inspector observed staff working with residents and was satisfied that all tasks were carried out in a pleasant and courteous way. Relatives commented that whenever they visit there is always adequate staff in the home. However at the time of arrival the inspectors were disappointed to find that no staff, were actually supervising the residents, two staff members were bathing residents whilst the other two staff were taking a break. The registered manager was again asked to ensure that staff are deployed in a way that ensures residents are supervised at all times. The inspectors examined three staff files and found in the main that the recruitment procedures had been followed. However on one staff file only one written reference had been obtained instead of the statutory two written references. The reference obtained was also an open reference entitled to ‘whom it may concern’, whilst the registered manager explained that this had been obtained by her in response to her written request the inspectors advised Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 17 that all references should be addressed to her or the registered provider and dated and that staff should not be employed until two satisfactory references have been obtained. Whilst the Criminal Records Bureau checks were not examined at this inspection, the registered manager gave her assurance that satisfactory clearances had been received for all staff currently employed. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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) The home is managed and run in the best interests of residents. EVIDENCE: Relatives and staff members were very positive in their comments about the homes manager and her style of management. Relatives and staff spoken to said they found the manager to be approachable, supportive and helpful. A new member of the management team has been appointed who will have the responsibility to maintain the homes administration systems and to support the manager in the day to day running of the home. This will provide the manager with additional time to spend on staff development and direct observation of care practices. Staff receive performance appraisal and staff spoken to had a clear understanding of their role and what is expected of them during their shift. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 19 As the registered provider does not manage the home she is required to carry out monthly visits in order to satisfy herself the home is being run in the best interests of the residents and that satisfactory standards are being maintained. The findings of these visits must be recorded and a copy of the record forwarded to the Commission for Social Care Inspection. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x x x x x Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 21 yes 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 33 Regulation 26 Requirement The registered provider must conduct her own inspection visits and forward a copy of her findings to the Commission for Social Care Inspection. Risk assessments must be in place and form an integral part of the care plan. Care notes must clearly document the the well being of the resident and must include full details of G.P. visits. Two written references must be obtained for each member of staff prior to employment. Staff must be deployed in a way that ensures residents are supervised at all times. Timescale for action 30/9/05 2. 3. 7 7 13 13 10/9/05 24/8/05 4. 5. 29 27 18 12 25/8/05 24/8/05 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 3 7 Good Practice Recommendations The assessment information could be in greater detail. Care plans should be revised to ensure they are working documents and clearly state the total care needs of the F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 22 Westholme 3. 4. 5. 6. 7 7 15 15 individual resident. staff should be trained in the management of challenging behaviour. the terminolgy used in care notes must be professional and subjective remarks must not be used. The kitchen facilities should be improved. attention should be given to how meals are served and appropriate crockery used. Westholme F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit 1, Tustin Court Portway 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 F57 F09 S9752 Westholme V207628 240805 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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