Inspection on 02/11/06 for Westholme Clinic

This inspection was carried out on 2nd November 2006.

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

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

Other inspections for this house

Westholme Clinic 08/12/08

Westholme Clinic 13/11/07

Westholme Clinic 30/06/05

Westholme Clinic 27/09/04

Westholme Clinic 10/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Westholme Clinic Clive Avenue Goring-By-Sea Worthing West Sussex BN12 4SG Lead Inspector Mrs G Davis Key Unannounced Inspection 10:00 02 November 2006 nd 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 Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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 Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westholme Clinic Address Clive Avenue Goring-By-Sea Worthing West Sussex BN12 4SG 01903 242423 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) carol@ashbournegrp.freeserve.co.uk Westholme Clinic Limited Mrs Patricia Ann Cummins Care Home 55 Category(ies) of Dementia (55), Dementia - over 65 years of age registration, with number (55), Mental disorder, excluding learning of places disability or dementia (55), Mental Disorder, excluding learning disability or dementia - over 65 years of age (55) Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 55 services users may be accommodated. Date of last inspection 18th November 2005 Brief Description of the Service: Westholme Clinic is a Care Home providing nursing and is registered to accommodate up to 55 people in the category of DE(E) (persons over 65 years with dementia), DE (dementia), MD(E), (mental disorder over 65 years), MD (mental disorder). It is a detached property located in Goring-by-Sea, in the town of Worthing. The accommodation for service users is arranged over two floors. The ground floor and first floor are served by a passenger lift. The bedrooms comprise predominantly of single occupancy, although there are three shared rooms. Westholme Clinic Limited privately owns the service and the responsible individual on behalf of the company is Mrs Shoai. The registered manager responsible for the day-to-day management of the home is Mrs Patricia Cummins. Fees range between £389 - £600 per week Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the unannounced visit; commencing at 10:00hrs for a period of 6 hours. The registered person had completed a pre-inspection questionnaire and information from this and the registered provider’s monthly monitoring reports, plus evidence from previous inspections, has been used to inform the planning, inspection process and, along with evidence gained during the inspection visit, this inspection report. During the visit the inspector spent time speaking to service users, relatives and staff members, examined documents and records and observed interactions between staff members and residents and the activities being undertaken. A tour of the building was carried out, which covered the communal areas, service areas and service users bedrooms, and it was considered that despite the institutional design and inevitable signs of wear and tear the establishment was reasonably comfortable, appropriately furnished and maintained to ensure safe surroundings to the residents. There was a high standard of cleanliness throughout the home and overall no odours were detected. The pre-admission assessments for four service users were seen and four care plans were tracked with any issues arising being discussed with Mrs Cummins the registered manager. The inspector saw menus and food records and toured the kitchen which was clean and in good order. The inspector sampled the meal provided at lunchtime. Records for the management of the service were also seen including, staff recruitment, health and safety, maintenance and fire records. Feedback given by the inspector to Mrs Cummins the Registered Manager and the Responsible Individual Mrs Shoai at the end of the visit highlighted the positive aspects of the care provided by the care home as well as other issues identified in the body of the report. Two requirements have been made as a result of this inspection. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A number of areas throughout the home have been redecorated and had new flooring put down. The Statement of Purpose was reviewed and amended in August 2006. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 7 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 Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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 Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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): 2.3.4.5.6. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Care plans of four residents were selected at random and scrutinised. Prior to admission appropriate information had been obtained and recorded and an objective overview as to whether their needs could be met by the home had been made. The potential residents were encouraged to visit to ascertain the suitability of the home, but most were unable to do so due to their condition and a representative – either family member or social worker – had done so on their behalf. Two of the residents selected did not have a written contract on file. They had been admitted to the home very recently and the residents’ representatives had not yet returned the signed contracts to the Manager. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 10 Intermediate care was not carried out at this home. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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): 7.8.9.10. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Four care plans were selected at random and were examined as part of the case tracking of four residents. The assessments were generally detailed in identifying the individual needs of the residents. The care plans provided the actions needed by the staff to meet all the resident’s needs as identified by their assessments and were reviewed on a monthly basis. Individual risk assessments had been undertaken and were included in the body of the care plan to allow staff members to access them and use them to inform their practice. A summary of care needs for each person was found in each of the bedrooms and an agency member of staff on duty at the time of inspection remarked on how useful this was as it ensured that the carers would understand how to meet the specific needs of each individual. Observation of staff carrying out their duties and on talking to some of the residents (most were unable to communicate verbally) it was clear that their Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 12 needs were understood and were met. Several people were observed communicating wordlessly with the staff members assisting them and it was obvious that the staff members were very aware of their communication signals and able provide them with what they required. Arrangements were made for the residents to attend any specialist clinics or health services required, and they were registered with a local GP Practice. The home had the appropriate equipment for the residents accommodated, with assisted baths, lifting hoists and other appropriate equipment such as pressure relieving mattresses as required. The medication administration records were examined and were generally well completed; no gaps were noted in the recording of medicines. Handwritten entries on the MAR charts were signed and dated. All staff members responsible for administering medication had received training. The administration of controlled drugs was satisfactory with double signatures obtained when a dose of medication was given and secure storage provided. The home has a contract with an approved contractor re the disposal and collection of any disposed medication. Information from previous inspections and observation of the interaction between the staff members and the residents showed that the residents’ privacy and dignity is respected at all times by the staff. Personal care is provided in the privacy of the resident’s bedroom or a bathroom. One resident commented that the staff members were very kind when attending to her needs. Others who were unable to comment appeared to be calm and content apart from one person, who when having her hair done became uncooperative and disturbed, but the situation was skilfully managed by the staff members thus resolving a potentially difficult situation without confrontation. The staff members were noted to be discreet when dealing with sensitive and personal matters with residents. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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): 12.13.14.15. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans were seen to contain information regarding the past interests of the residents. Currently various carers undertake the provision of activities on a daily basis. The activities carried out with the residents were mainly tactile - such as hand and feet massage - or reflected the personal interests of the residents. One visitor spoken to said that she considered her husband received much more stimulation at Westholme than he had at the Care Home he had been in previously. Special occasions such as Halloween were celebrated and the decorations were still up from a Halloween Party that had taken place the night before. A Barbeque had been held in September and there were plans for some events taking place in November and December. The home has an open visiting policy and visitors are welcome to sit in the visitors room, the communal areas or in the residents’ own bedrooms if Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 14 preferred. Those visitors spoken to confirmed that they were made welcome at any time that they called in. The kitchen was visited during the course of the morning and was found to be clean well ordered and appropriately equipped. All required records regarding fridge temperatures etc were available and recorded on a daily basis. The cook discussed the new menus that were being tried out. Inspired by a cookbook of recipes from the period of 1940-50, the meals had proved to be very popular with both residents and their visitors. Visitors present at the time of inspection made comments to the inspector such as “The menu’s excellent better than any other home that I’ve visited” and “The food is very good”. The meal was sampled by the inspector and was found to be tasty and well cooked. The menu for the week was available and identified that a wellbalanced, varied and wholesome diet was provided to the residents. The kitchen catered for two other homes owned by the company as well as Westholme. On observation the staff members were seen to be courteous and discreet with any help that was required and appropriately deferential to any wishes that the residents expressed Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a complaints procedure in place that states that complaints will be responded to within a maximum of 28 days. On checking the complaints log it was noted that there had been five complaints recorded since the last key inspection. Appropriate action had addressed the issues and the outcomes recorded. One resident confirmed that she knew how to complain and who to, all other residents were unable to comment. Relatives also commented that the Manager was extremely approachable and they would have no hesitation in complaining if there was a problem. Training records showed that all staff attended training on adult abuse and were aware of what to do if they suspected that abuse had taken place. The staff on duty confirmed this at the time of inspection. Plans were in place to ensure that the training is regularly updated. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 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): 19.21.24.26. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A tour of the premises was made and generally the premises were considered reasonably well maintained. The building was rather institutional in design and difficult to make homely, however effort had gone into trying to make the home comfortable and less severe. Residents’ bedrooms had been personalised with small possessions and photos where possible. One visitor described her husband’s room as basic but considered it more than adequate. She explained his condition caused him to destroy most of his possessions. There were a number of areas for residents to sit in and long corridors to provide residents plenty of walking area to wander in. The lounge, dining room and conservatory were comfortably furnished and pleasantly decorated; however the lounges on each unit were institutional and unattractive. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 17 Some areas show the inevitable signs of wear and tear, particularly the toilet and bathroom areas, which have not been refurbished since the home was built. These were considered to be stark and in need of the replacement of some facilities and equipment, a change of flooring and redecoration. Two modern showers have been provided. Some re-decoration and replacement of carpets in some areas had taken place since the last Inspection. An attractive conservatory overlooks a large and secure garden with a patio area for residents to sit out in fine weather. The local fire service had carried out a fire safety check and improvements required following this assessment had been completed. The home was very clean and fresh in all areas with only one bedroom odorous. Given the degree of disability of the residents this was considered to be an inevitable result of advanced dementia. Stringent cleaning routines were in place to deal with any incident of incontinence. A separate laundry area was provided with hand washing facilities and all washing handled following the correct infection control procedures. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 18 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): 27.28.29.30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There were 54 residents living at the home at the time of inspection. On the day of inspection there were three qualified Nurses and seven nonqualified carers on duty excluding the Manager. Additionally there was one domestic cleaner, two cooks and one kitchen domestic. The number of trained nurses dropped to two in the afternoon and the number of untrained carers increased by one. There were a sufficient number of waking night staff members on duty to reflect the numbers and needs of the residents and the layout of the home. . An examination of staff files and conversation with the care staff team revealed that there was a good skill mix and level of knowledge of the resident group within that team. There was a recorded rota that showed which staff members were on duty at any time of the day or night that accurately identified those on duty at the time of inspection. The Manager informed that the home used Bank and Agency Staff to cover any vacant hours that might arise. Three files of staff members that had been recruited since the last key inspection were examined and seen to contain all information required by the Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 19 National Minimum Standards. New staff members were only confirmed in post following the completion of a satisfactory Police and POVA Check. It was seen that the registered person operates a thorough and robust recruitment procedure. Personal files were examined for four members of staff and it was seen that a number of in-house training sessions on relevant service related subjects had been undertaken including Moving and Handling, Fire Safety, and Adult Abuse. It was evidenced that new members were given an induction. Some staff had NVQ level II and above and nine members of staff are currently undergoing NVQ training The Registered Manager has completed NVQ IV and the Registered Manager’s Award and is currently undertaking an ASET course in Dementia Care with five other senior members of staff. Staff members confirmed that they found the manager supportive and they considered that they were given enough information regarding the residents needs to be able to provide good care. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 20 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): 31.33.35.38. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Despite the fact that there is not a formal Quality Assurance System in place, all feedback from relatives and staff members, plus observation of the conduct of the staff and residents, and scrutiny of the records would indicate that the home is appropriately managed EVIDENCE: The registered manager has an extensive amount of experience in working with people with dementia and holds the NVQ level IV in Care Management and has the Registered Manager’s Award. The registered provider carries out a regulation 26 visit and report on a monthly basis and these indicate ongoing monitoring of the service. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 21 Any complaint feedback would be used constructively to improve the performance of the home. There does not appear to be a formal Quality Assurance System in place to gather feedback from service users (in most cases from their representatives due to their disability) or others, apart from a yearly questionnaire that is sent out to relatives. The Manager informed that the questionnaires were due to be sent out in the immediate future. There was not a development plan available at the time of inspection. The registered provider should introduce a Quality Assurance system in order to produce a yearly report that can be used to inform practice and the new business plan. The policy of the home is not to manage the financial affairs or handle large sums of money for the residents and any expenditure on the residents’ behalf is billed to their representative to manage for them There is a programme of Formal supervision for all staff. Staff members confirmed that they found their manager firm but fair and supportive.” You know that if you are told off by Mrs Cummins you have deserved it” All systems and equipment had been serviced and maintained at the appropriate intervals. All accidents, injuries and incidents were recorded and reported to the appropriate authorities. Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 22 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 3 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 Standard No Score 16 3 17 X 18 3 3 X 1 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP33 Regulation Requirement Timescale for action 01/03/07 2 OP19 24.1(a)(b) The registered person should put 2.3. effective quality assurance systems into place. The results should be used to inform a suitable business plan 23.2 (b) The registered person should 01/03/07 (d) ensure all areas of the home are well maintained, comfortable and homely including the toilet and washing facilities. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westholme Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Clinic DS0000024239.V308601.R01.S.doc Version 5.2 Page 25 - 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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