CARE HOMES FOR OLDER PEOPLE
Westholme 24/28 Victoria Road St Annes On Sea Lancashire FY8 1LE Lead Inspector
Mrs Lillian McMullen Unannounced Inspection 11:00 25 January 2006
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.V272265.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.V272265.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.V272265.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) 24th August 2005 Date of last inspection 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. A manager is employed who has applied for registration with the Commission for Social Care Inspection. The accommodation is on 3 floors, and is currently 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 DS0000009752.V272265.R01.S.doc Version 5.1 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 11.00am and took place over 6 hours. The Inspectors spoke to the manager, the homeowner, a number of staff and two relatives. Part of the inspection was spent on looking at policies, procedures, care documentation and the environmental standards within the home. Prior to this inspection, resident and relative comment cards provided by the Commission For Social Care Inspection was sent to the home for completion. At the time of writing this report no completed comment cards have been returned. What the service does well: What has improved since the last inspection?
A new manager has been appointed and a new senior management structure has been developed, this now ensures that a designated senior staff member is on duty at all times. Care plans have been reviewed and now provide greater clarity on the needs of the residents and the measures to take to meet the stated need. The refurbishment programme continues and the work carried out to date has been completed to a good standard. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 6 The manager has introduced new work practices that ensures residents are supervised at all times and that staff are deployed in a way that promotes resident safety and wellbeing. 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 DS0000009752.V272265.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Westholme DS0000009752.V272265.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All the above core standards were assessed at the previous inspection. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 and 7 in part Care Plans have improved, however further development of these documents is required to ensure they fully reflect the assessed needs of the residents. Privacy is respected and staff are informed of the measures to take in order that personal privacy and dignity is afforded. EVIDENCE: The new manager has reviewed the care plans they now provide greater clarity on the needs of the residents and the measures to take to meet the stated need. However more work is required to ensure to ensure they fully reflect the assessed needs of the resident. Care plans must also contain a risk assessment that fully informs staff of the action to be taken to minimise all identified hazards. The manager is fully aware of the importance of ensuring residents receive a balanced and nutritional diet. A number of staff have completed a training course entitled ‘dementia and nutrition’ and the inspector feels that this knowledge could be best used by implementing nutritional assessments, which should then form an integral part of the care plan.
Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 10 Resident’s privacy is respected and staff are informed of the measures to take to ensure that every possible effort is made to protect personal privacy and dignity. Under the refurbishment programme all the new bedrooms have en suite facilities and all personal care is provided in the residents bedroom. The inspector advised that privacy and dignity be addressed through the induction process. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 14 Social activities are encouraged to suit the individual and the group. Contact between residents and their families are encouraged to help maintain relationships. EVIDENCE: Two visitors were present during the inspection and they confirmed that they were free to visit at any time. Both confirmed they were satisfied with the care provided at Westholme. Residents are free to entertain their guests in the privacy of their bedroom alternatively they are free to use one of the lounge areas or the dining room. As one of the quite lounge areas has been converted to bedroom space as part of the refurbishment programme the inspector asked that some thought be given to recreating another quite area were residents can entertain their visitors in private. At present a limited activity programme is in place, which includes a weekly physiotherapy class. The manager explained that due to the limited attention ability of the residents it is difficult to arrange group activities. However in order to provide appropriate stimulation a number of individual activities have been introduced that include taking residents out to the local public house and
Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 12 then lunch out and taking a resident out each day to collect her newspaper. This initiative is to be further developed by introducing more activities based on the individual interests of residents. The way in which the social needs of the residents are to be met will then be documented in the care plan and time will be built into the staff daily schedule to ensure that all residents have the opportunity to enjoy their preferred activity. In addition it was pleasing to note that effort has been made to purchase items that will occupy residents and promote social interaction. There are well-maintained gardens to the front of the property and as part of the refurbishment programme the rear garden area is to be decked in order to provide safe space for the residents to enjoy during the summer months. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A complaint policy is in place to enable concerns to be raised and responded to. The procedure for the Protection of Vulnerable Adults requires amending to ensure it fully protects residents. EVIDENCE: The home has a complaints procedure, which ensures that complaints would be responded to within 28 days. The complaint procedure is contained in the Service User Guide and provided to residents and their relatives upon admission. Some advice was provided by the inspectors in relation to improving the recording of any complaints received. The inspectors advised that the outcome of the investigation should be recorded together with the date the complainant was notified of the outcome of the investigation. The home has received two complaints since the last inspection. The Commission for Social Care Inspection investigated the complaints and found some areas to be substantiated. It was further advised that as residents are not always able to make their views and opinions known relatives views could be sought on a more frequent basis. This could be achieved by sending anonymous requesting their views and opinions as to the service provided. The Procedure for the Protection of Vulnerable Adults was examined and was found to require reviewing to fully comply with the D.O.H. guidance document ‘No Secrets’. The reporting and recording protocols should be clearly stated in
Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 14 order that residents are protected whilst staff take appropriate action without contaminating evidence. In order to protect residents systems must be put into place that provides evidence of the action that has been taken should a member of staff be found to have a criminal conviction. Whilst a criminal conviction does not automatically mean that a person can not work with older people management must be able to demonstrate that residents are not placed at risk. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 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 the following standard(s): 26 Measures are taken to minimise the risk of infection. EVIDENCE: At present fifteen staff are on a infection control training course, this is being provided by Blackpool and Fylde College and is a distant learning modular course. The laundry room is sited at the rear of the home and is well equipped with commercial washing machines that ensure laundry is washed at specified temperatures. Through the refurbishment programme better access is being created to transport soiled laundry through the home. All clinical waste is appropriately disposed of and the home has a contract for the safe removal of all waste. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 16 At the time of the inspection an odour was detected, however the homeowner has made progress in replacing some floor coverings and has plans to replace all carpets with a non absorbent type of floor covering. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 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 and 30 Staffing levels are satisfactory to meet the needs of the residents. Induction training should be appropriately recorded. EVIDENCE: At present induction training is provided which is documented, however, concerns was raised by the inspectors regarding the time scale in which the training was provided. It was noted that all induction training had been provided on the same day, which in the opinion of the inspectors was unreasonable, as staff need time to assimilate and understand information. The inspectors also provided some advice in relation to The Skills for Care induction standards. Individual records of training were viewed which confirmed that staff had attended some external training courses, however these records should be extended to record all internal and external training undertaken. The manager and homeowner were also advised to develop an up to date training matrix to be able to identify collectively the skills and knowledge of the staff team at any given time and to identify when training updates are required. The manager and homeowner was informed of the mandatory training that staff must attend and the need to have a named first aider on duty at all times. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 18 From discussion with the new manager the inspectors formed the opinion that she is pro active towards training. The manager discussed her intention to enrol staff on ‘training the trainers’ in order that staff can have areas of responsibilities and mentor other staff members. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 19 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 The new manager is keen to manage the home in a way that supports staff to ensure residents receive consistent quality care. EVIDENCE: A new manager has been appointed and has been in post for two months. The homeowner and manager are currently working closely together and both are experienced in caring for vulnerable adults. The Inspector was informed that the manager has attained the NVQ level4 award. Since her appointment the manager has achieved positive improvements in developing systems that ensure good care practices. It was reassuring to note that the new manager recognises that a lot of work and investment is needed to improve standards and the inspectors hope these positive improvements continue.
Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 20 During the course of the inspection the inspectors examined a number of the homes policies, whilst these were quite detailed it is evident that these are a package that have been purchased to meet the ISO 9002 Quality assurance requirements and as such a number needed reviewing and personalising to reflect the specific service provided at Westholme. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 21 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 13 Requirement Risk assessments must be in place and form an integral part of the care plan. (Not met from previous inspection) The abuse procedure must be reviewed to incorporate the correct reporting and recording protocols as stated in ‘No Secrets’ In order to protect residents evidence must be available to confirm that any criminal convictions declared by staff have be investigated by the manager or homeowner. Timescale for action 14/02/06 2. OP18 13 14/02/06 3. OP18 18 25/01/06 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. Refer to Standard OP3 OP7 Good Practice Recommendations The assessment information could be in greater detail. (Not met from previous inspection) Care plans should be further developed to reflect the
DS0000009752.V272265.R01.S.doc Version 5.1 Page 23 Westholme 3. 4. 5. 6. 7 OP28 OP16 OP15 OP7 OP16 assessed needs of the resident. A training matrix should be developed in order that the training of staff is clearly evidenced. More frequent anonymous questionnaires should be sent to relatives in order that their views and opinions are as to the service provided. The kitchen facilities should be improved. (Not met from previous inspection) Care plans should contain a nutritional assessment. The complaint procedure should be developed further to record the outcome of any investigation together with details of the date the complainant was notified of the outcome. Westholme DS0000009752.V272265.R01.S.doc Version 5.1 Page 24 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
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