CARE HOMES FOR OLDER PEOPLE
Westholme Clive Avenue Goring-By-Sea Worthing, West Sussex BN12 4SG Lead Inspector
Gill Davis Announced Thursday, 30 June 2005, 09.30am, V225987
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. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Westholme Clinic Address Clive Avenue, Goring-By-Sea, Worthing, West Sussex, BN12 4SG 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) 01903 242423 01903249997 Westholme Clinic Ltd Mrs Patricia Ann Cummins CRH 55 Category(ies) of DE(E)-55, MD(E)-55, DE-55, MD-55 registration, with number of places H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: A maximum of 55 service users may be accommodated. Date of last inspection 27/09/04 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. The service is privately owned by Westholme Clinic Limited 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. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first of the two inspections (minimum) that an inspector must make in a year. On this occasion this inspection was announced and took place over one day in June 2005. The aim of this inspection was to find out how the home cared for the residents and whether sufficient staff members were available to provide a safe and stimulating environment for the residents. Surveys for residents/their representatives and other visitors were provided to the home before the inspection date, one was returned and the content from that plus information contained in the pre-inspection questionnaire has been used to inform this report. Where possible the opinions of the residents or their visitors as to how well the home did this were sought. The relatives of three residents were spoken to by telephone and their comments have been included. The inspector was able to speak to a number of visitors who all spoke very highly of the service that the home provided. One person said that he considered that his mother in law was very well looked after - he said, “I’m very happy with the way she is looked after, she’s always lovely to look at”. Another, who was present with her mother, stated, “ I come in two or three times per week, I always feel welcome.” Observation of the body language of those residents who were unable to give the inspector verbal opinions confirmed that they were content and comfortable with their surroundings. On occasions the inspector witnessed sensitive and discreet interaction of staff members with several individuals who were agitated, helping them to regain confidence and calm. A tour of the home took place. Staff and care records were inspected as well as the Home’s Statement of Purpose, Service Users Guide and some of the Policies and Procedures. All of the staff on duty, and most of the residents were spoken to during the course of the inspection. There were no requirements or recommendations arising from this inspection. What the service does well:
All of the staff members are permanent or bank staff and the good relationships between staff members and residents were shown during the course of the care staffs’ work with the residents, with much laughter and good humour. The residents who were able to communicate verbally said that the staff were kind and that they liked being there, mostly the residents were unable to hold a conversation with the inspector. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 6 All of the relatives spoken to spoke of how well the home had dealt with the admission of their relative and that they were always made to feel welcomeone person said “ I always feel welcome” another “ we were told we could come anytime we like and take them as they were”. The care plans identified the preferences of the residents and it was seen that they were given choice in all that they did and that there were no petty rules to observe, for example they could go to bed and get up at whatever time they wished and staff would be careful to observe their privacy at all times. Observed interaction between the care staff and those who were unable to converse with the inspector confirmed that the care staff treated the residents with respect and dignity in a discreet and unobtrusive manner. The care plans for each individual were very informative and regular review of the care plans and other records help the care staff to give suitable emotional and physical support to the residents. There is a thorough and robust recruitment procedure with excellent staff records. The general environment is well maintained with attention to cleanliness. The home is generally comfortable for the residents to live in with plenty of space and light. What has improved since the last inspection? What they could do better:
From the feedback from relatives and residents there appeared to be very little that they considered needing changing or improvement. One relative said that there had been some minor miscommunications occasionally but overall all the feed back from various sources was positive. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 7 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. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 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 standard(s) 1.2.3.6. All prospective residents, or their representatives, have a number of opportunities to make an informed choice about whether they want to live at Westholme and have their needs thoroughly assessed prior to admission by a senior member of staff. Those that choose to live at the home have a written contract/statement of terms and conditions with the home that they or their representative has agreed to. Intermediate care is not provided by the home. EVIDENCE: The home provides a comprehensive Statement of Purpose and Service User Guide to all prospective residents, their families and their Care Managers. Everybody concerned with the prospective resident is encouraged to visit as often as they like and a four-week trial period is used to allow the new resident to settle in and make sure that they are happy with the situation. A review of the placement takes place after six weeks and where possible the resident or their representative is fully involved and contributes to any changes to the care plan that might be made. A signed contract was seen on each of the resident’s personal files. Most of the residents were unable to speak to the inspector about their experiences on admission because their disability precluded it. The relatives present at the
H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 10 time of inspection confirmed that they and their relatives had been made to feel welcome at the time of admission. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 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 standard(s) 7.8.10. Where possible residents or their relatives/representatives are involved with the drawing up of their care plans, which contain detailed information of how the care and health needs of the residents should be met. From evidence gathered it would appear that the staff group respect the privacy and dignity of the people living at Westholme EVIDENCE: Where residents are not able to be involved with the drawing up of their care plans, then the residents relative or advocate is involved. This was confirmed by a relative who said, “they always consult us about things to do with my wife, I went to her review recently” There was some mixed opinions about how well the home communicated but predominately relatives confirmed that they were informed of any change in their relatives care. The care plans included up to date information regarding the residents’ current health status and had been reviewed on a monthly basis. Medication was not examined on this occasion. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 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) 12.13.15. The residents are provided with the opportunity to follow their chosen lifestyle at all times. Where the resident is unable to make those choices and decisions for themselves, family or representatives are consulted to make sure that the person has as much control over their lives as possible. A wholesome and balanced diet is provided EVIDENCE: All preferences and interests are recorded on the care plans. The inspector witnessed staff members helping the residents to make choices that were within their capacities. One resident told the inspector “ It’s all right to be here, I feel safe and comfortable here” and relatives were complimentary about the staff group and the care that their relatives received. On the day of inspection several families visited and informed the inspector that they were always made to feel welcome whenever they visited. Staff members carry out activities with the residents and these vary between quiz games, bingo and one to one activities. The inspector was able to observe members of staff interacting with the residents and witnessed some sensitive management of potentially difficult behaviour. The inspector joined the residents for lunch and enjoyed a tasty meal. During the meal the inspector was able to observe the care staff carrying out their duties in a discreet and dignified manner.
H60-H11 S24239 Westholme V225987 300605 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 residents or their representatives are sure that they can trust the home to protect them as far as possible from bad practice and unacceptable behaviour from others. EVIDENCE: Due to their disability most of the residents would be unable to complain. The home has policies and procedures in place to ensure that action is taken if a resident or their representative was worried and a complaint book is provided to record any issue that might arise. A visitor said “ My mother has been here for four years and I have only had to complain once” she confirmed that the matter that she had complained about was dealt with quickly and to her satisfaction. The home has clear instructions for staff members as to what to do if abuse of a resident is suspected and the members of staff that were spoken to in depth were knowledgeable about the procedure to take and had received training. The recruitment files examined showed that all the checks to ensure proper security screening on all applicants had been carried out. H60-H11 S24239 Westholme V225987 300605 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) 19.20.23.24.26. The home is a comfortable, pleasant and well-maintained building, which is generally decorated and furnished to a good standard. As well as a choice of communal day space it provides each resident with a room that has been furnished to meet their wishes and needs. Regular maintenance makes sure that the environment is safe. There was a good standard of cleanliness. EVIDENCE: During the course of the inspection the majority of rooms were visited to make sure that the environment was safe and comfortable for people who live there. It was seen that many residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. There is an attractive new conservatory for the residents to use and this leads out to an enclosed garden providing a pleasant place for the residents to enjoy in good weather. On the day of inspection, Westholme was clean, and free from offensive odours. There is an ongoing refurbishment plan and on the day of inspection the fire alarm system was being upgraded.
H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 15 Risk assessments regarding the safety of the building were in place. Policies and procedures were available for staff about the control of infection, and the safe disposal of clinical waste. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 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) 27.29.30. Westholme has an adequate number of staff members with appropriate training and skills to provide competent care to the residents at all times. EVIDENCE: A random selection of staff files was looked at including the most recently appointed member of staff. All the required security checks had been carried out and evidence of identity and qualifications and supervision notes were also on file. Appropriate induction training had been undertaken with the newest member of staff. the remaining staff members had undertaken in-house training in service related topics. A staff member told the inspector “ the National Vocational Qualification has helped a lot particularly those of us where English is not our first language----some of the idiosyncratic sayings have been explained”. The staff files contained all evidence required including work permits and visas as appropriate. A satisfactory number of staff members are employed, making sure that the home is appropriately staffed at all times. H60-H11 S24239 Westholme V225987 300605 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) 31.33.37. The home is run in a manner that offers protection to all aspects of the residents’ interests. EVIDENCE: The registered manager who is undertaking the Registered Manager’s award currently has all the skills and competence to discharge her responsibilities fully. Other senior managers in the company support her. There are comprehensive policies and procedures in place to provide protection to the residents and guidance to staff members on how to carry out their duties; records were found to be accurate and up to date. In particular the individual care plans contained vital information regarding the residents’ health and welfare needs and promote a uniform approach to the care and protection of the residents. H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 18 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 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 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x 3 x H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 19 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 Regulation Requirement Timescale for action 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 Good Practice Recommendations H60-H11 S24239 Westholme V225987 300605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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
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