Inspection on 25/05/05 for Westholme

This inspection was carried out on 25th May 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 20/12/05

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 25 05 2005 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 J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westholme Address Thornhill Road Upper Wortley Leeds LS12 4LL 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) Category(ies) of registration, with number of places 0113 2638203 0113 2638203 Leeds City Council CRH 40 Old age (39) Physical disability (1) Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No service user under the age of 50 years is eligible for the 1 PD placement Date of last inspection 1st February 2005 Brief Description of the Service: Westholme is a care home owned by Leeds City Council and managed by Mrs. O,Mally.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 50years. 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 J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 9.20am finishing at 4pm. 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 18 service users and 7 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, staff recruitment files, medication records, minutes of meetings with residents and staff and maintenance records. The inspector looked around part of the building. The atmosphere within the home was open, friendly and welcoming. 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 at the home work hard to ensure the residents who come to stay at Westholme feel welcomed, safe, and confident that the necessary help with their care will be given by staff in a professional and friendly manner. Residents gave positive comments about living at Westholme such as “Its nice here, staff are kind and helpful.” Residents are consulted about how they feel, and what changes to services they would like to see. Residents are pleased with the standard and choice of food offered at the home. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 6 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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 J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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) 1, 3,4,5. 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. EVIDENCE: The manager has recently started to assess people before they move into the home to ensure their needs can be met. A relative of a recently admitted resident who said “staff had been very helpful and shown him the room his mother would occupy and shown him around the home” confirmed this. A comprehensive written pre admission assessment was seen in a care plan. Written documentation about what the home provides is available in areas around the home. A notice advised people of the most recent CSCI inspection report and where it was held. Since the last inspection a number of very dependant residents have moved from Westholme. As a result staff said they now had more time to spend with the residents. The home now complies with the registration categories. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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) 7,8,9,10. Staff at Westholme meet the health and care needs of residents. Medication for residents is managed in a safe and professional way by staff. It was observed and confirmed by a number of residents that they are treated with dignity and respect by staff at Westholme. EVIDENCE: Information in residents care plans has improved. They are clear in the action to take when a resident care needs change. The plans are reviewed on a monthly basis and changes in care needs are responded to. There was information about external health professionals visits. The chiropodist said staff ensured she was able to treat residents in private. Residents said staff respect their privacy when providing support with care needs. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 10 The pen picture in the care plans gives staff information about the resident’s life before moving to Westholme Assessments need to be reviewed for residents with poor mobility, who maybe at risk of falls. A member of staff was seen administering medication safely. She said she was taking an external training course about the responsibilities of dealing with medication that she found helpful. No errors were noted on the administration of medication records seen. Staff were observed treating residents with respect and dignity throughout the inspection. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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) 12,13,14,15. 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. Residents are consulted about how they wish to live their life on a daily basis. Residents enjoy food served at Westholme. EVIDENCE: Residents said, “ Its nice here, staff are kind and helpful”. Residents confirmed they are able to spend the day as they chose within the home. One resident had been to the cinema with a member of staff. Another had been out shopping. Another said, “I was afraid to come into a home, but now I love it, I have made a friend” Staff said they were able to spend more social time with the residents since the dependency levels of residents had decreased. Staff and most residents participated in verbal banter and the social atmosphere was good throughout the day. A visitor was very positive about the care his mother receives. He said, “ my mum is very content, she is looked after properly.” A recent residents meeting in April 2005 confirms that residents are consulted about services at Westholme. A number of changes have been suggested about changes to the menus. In discussion with the chef, it has been agreed that a full review of menus will soon take place and residents will be consulted Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 12 throughout the process. The chef said since she no longer cooked for external luncheon clubs, she had more time to spend to improve the standard of food for the residents at Westholme. The home now uses full fat milk to increase the nutritional value to residents with low weight. Residents were unaware what was for lunch. It is recommended that a board displaying the daily menu is placed in the dining area. Residents said this would be a good idea. During a tour of the building, it was noted that the kitchen cleanliness has improved. However, it was also noted that the kitchen floor requires replacing, the bins were rusty as were the kitchen trolleys. A heated trolley transports meals served on the first floor. It is recommended that a written risk assessment be done to minimise the risk of burns. The introduction of a hazard sign on the trolley will alert people to the risk. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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) 16,18. 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: All residents are given a copy of the complaints procedure. There are copies displayed in the hallway and lounges. One complaint has been recorded since the last inspection. It had been appropriately 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. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 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) 19,24,26. 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: Evidence of up to date fire drills, and fire safety equipment was seen. Residents can choose to sit in small lounges on the ground and first floor. One lounge acts as a bar where alcoholic drinks can be bought, and where residents can smoke if they wish. All room are single but have no en-suite facilities. Rooms were highly personalised with pictures, photos and nick knacks the residents had brought from their home. The standard of bedding is very poor. It is worn, mismatched and must be replaced. The home is a good standard of cleanliness, with no malodour in communal areas. It was noted that two rooms require replacement of carpets. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 15 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) 27,29,30. The providers, Leeds City Council Social Service Department, have a robust interview process when recruiting staff. However, this is undermined by the department’s practice of allowing employees to commence employment before Criminal Records Bureau check is known. This could result in an employee inappropriately working with vulnerable adults. This practice should stop. Staffing levels have improved since the last inspection, reducing the need to use agency staff who are not know to residents. The staff team at Westholme are trained and supported to provide good levels of care to residents. EVIDENCE: Since the last inspection the manager has recruited additional senior care staff. This has resulted in shared management responsibilities for resident care and staff support. Staff said morale was high. In discussion with staff one said” it’s a pleasure to come to work.” Two members of staff were able to explain their responsibilities when on duty and said” there is good teamwork”. The recruitment files of two staff members were looked at. They both contained relevant documentation including, notes of interview, application form, two written references a copy of hours to be worked. However, it was also evident that one new member of staff had commenced work before Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 16 information regarding a Criminal Records Bureau check was completed. The manager, who said she was following the instructions of the providers Leeds City Council Social Services department, confirmed this. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 17 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) 31,32,36,38. Wesholme is a well managed home where residents and staff are consulted about the standards of service. The manager has yet to be registered with the Commission for Social Care Inspection. The health and safety of residents and staff is promoted. EVIDENCE: The manager, Mrs O’Malley, is undertaking a management qualification. She has many years experience of managing residential care. She has recently returned to manage Westholme after a number of years managing other services for Leeds Social Services. She has yet to be registered with the CSCI as the manager of Westholme. Residents and staff said she was approachable and supportive and makes clear her expectations of standards of care to residents by staff. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 18 Recent meetings for residents and staff had been held. Minutes of these meeting were seen and confirmed residents are consulted about proposed changes to services at the home. Evidence that one to one staff supervision takes place was seen. Staff said they valued the sessions as it gave them chances to discuss training opportunities. Health and safety checks take place on a regular basis to ensure the building is safe for both residents and staff. No hazards were noted during the inspection. The fire safety procedures were looked at and appeared up to date. Staff are attending up date training on the safe moving and handling. They said they had also had training on infection control. Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 19 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 N/A x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x x 3 x 3 Westholme J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 20 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. 2. Standard 31 15 Regulation 13 13 Requirement Risk assessment relating to service users must be reviewed and up dated. the kitchen floor must be replaced in addition to the rplacemenyt of bins and trolleys used by the kichen staff.A risk asssessment must be undertaken for the hot trolley. Bed linen must be replaced and 2carpets in identified residents rooms. 50 of care staff must NVQ level 2 by Dec.2005 The manager must be registered with the CSCI as manager of Westholme and complete NVQlevel4 by Dec.2005 Timescale for action 30 June 2005 30 July 2005 3. 4. 5. 24 28 31 23 18 9 30th July 2005 30 December 2005 30thJuly20 05 & 30thDecem ber2005 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 15 Good Practice Recommendations A menu board should be displayed in the dining room. J52 S33302 Westholme V223317 250505 Stage 4.doc Version 1.30 Page 21 Westholme Commission for Social Care Inspection Aire House Town Street Rodley 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. 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