Inspection on 14/03/07 for Westhope Mews

This inspection was carried out on 14th March 2007.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westhope Mews 27/01/06

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Thorndene

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Westhope Mews 6 Denne Parade Horsham West Sussex RH12 1JD Lead Inspector Mrs Ann Block Unannounced Inspection 14th March 2007 09:00 Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 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 Westhope Mews DS0000062779.V330516.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 Adults 18-65. 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. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhope Mews Address 6 Denne Parade Horsham West Sussex RH12 1JD 07768 461144 01403 791794 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) Westhope Ltd Mrs Sally Teresa Kelly Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2006 Brief Description of the Service: Westhope Mews is registered to provide care for up to eight service users with learning and physical disabilities. Service users are accommodated on the ground floor. A separate unit on the first floor accommodates people under the supported living scheme and is not part of the registered home. The building is a detached house situated in the town centre of Horsham and was converted from business premises two years ago. Local amenities such as shops, leisure centres and public transport are nearby. Each service user has a bedroom with en-suite facilities. Six bedrooms can accommodate people who are wheelchair users. Communal space includes a lounge, dining room and activity room. There is an enclosed courtyard to the front of the property. The responsible individual on behalf of the organisation in Mr Dermot Hurford and the registered manager in charge of the day-to-day running of the home is Mrs Sally Kelly. At the time of this inspection fees ranged from £1135:02 to £1951:91 per week. Service users pay individually for chiropody, hairdressing, toiletries, papers and magazines and in one case an annual holiday. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of a key inspection carried out by Ann Block which included an unannounced visit to the home on Wednesday 14th March 2007. The day was spent at Westhope Mews talking to service users, a visitor, staff and the manager and observing day to day activities, care and support. A sample of records was seen. Feedback was given to the manager during the inspection. Service users, staff and a relative gave their full cooperation to the process of gathering evidence for service provision. Judgements made from conversation, observation and records suggest that service users are well cared for and have a good quality of life. A supply of survey forms was sent to the home shortly before the inspection. At the time of the visit to the home, two had been returned from service users and two from staff. Comments from staff included: ‘This care home is of the highest standard. The service users have an excellent quality of life. Training is ongoing. It is a great company to work for. I think this care home is one of the best I have ever worked for and I have worked for quite a few.’ ‘The home helps to promote individuality and the right for service users to make their own choices. It’s not institutionalised, it’s more a homely environment than a care home.’ A relative was passionate about the high standard of care not only for his daughter but for all the service users. Service users praised the home and the staff, its homeliness, friendliness and the range of activities available. Where information obtained at the last inspection remains pertinent, it has been incorporated into evidence for this report. What the service does well: Service users have a good quality of life where they have plenty to occupy them and staff who are kind, competent and motivated to support them. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 6 Service users’ safety is maintained through staff presence and a safe environment. Service users are encouraged to be healthy and receive medical treatment when necessary. Staff are aware that service users have the right to have full and interesting lives where they can make real choices. Staff look for opportunities for service users to enjoy physical exercise, social activities and develop daily living skills. Staff feel they are well supported by each other and management. 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. The summary of this inspection report can be made available in other formats on request. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported through good admission processes to move into a home which suits them. EVIDENCE: A statement of purpose and service users guide is readily available to interested people which gives clear detail of the home and the service it provides. A pictorial copy has also been produced with one displayed in the entrance hall. Systems are in place for service users to visit the home and meet other service users and staff where this would benefit them. A service user was admitted recently and the process of admission was discussed with the manager and a support worker and associated records were seen. A full assessment process had been carried out including meeting the service user at her former home and liaison with professionals. Some personal belongings were transferred to her new room so she would feel at home when she moved in. The manager had been careful to ensure that the service users needs could be met at the Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 9 home before a final decision was made. The father of another service user spoke of the processes of moving his daughter into the home a few months ago. He was very happy with the admission process and felt his daughter had settled in exceptionally well, largely due to the way the transfer was managed by staff at Westhope Mews. Each service user starts the placement on a trial basis as stated in their contract. Some service users currently living at the home have complex needs. Whilst chatting with some of the service users concerned said they were happy at the home and felt their needs were well met. One said: ‘it is the best place I know, I am so lucky to be here’. Another said that: ‘compared to my last place this is like a proper home’. Training is planned to support staff work to meet service users individual needs. Each service user has a contract. Contracts seen gave good detail of the rights and responsibilities of the organisation and the service user. Additional contractual information is contained in the social services placement agreements. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live a life where they can make decisions and take risks whilst being properly supported to do so. EVIDENCE: Each service user has a series of folders containing information about care needs, current goals, risk assessments and supplementary information. The aim is to present information so that staff have easy and understandable guidance for each service user in key aspects of their care. The files are well set out and regularly reviewed. The system is built up from the time of admission and evidenced development of skills and independence for the service user. Service users spoken with as part of case tracking confirmed entries written in their care plan. Observation of practice showed that staff Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 11 had a good understating of individual care and support needs. One service user said: ‘staff know what I want here and I know I’ll get it’ As a useful addition to the care file, more specific detail of how service users like their care to be provided is being written up. The two examples seen were well personalised and would assist anyone working with the service user to respect likes and dislikes. Each service user has a keyworker who takes a particular role in working with the service user, assists in the care planning process and is involved in setting up information for the regular formal review process. In addition to this, each goal is reviewed using evidence from a separate record of achievements. Service users are involved in setting up their care plans where able and interested, where this is not practical staff make sure they use observation, discussion with others who know the service user and previous history to identify client strengths and needs. Staff are excellent in recognising service users rights to be the decision makers. Everything possible is done to ensure that service users wishes are identified. Where decisions have been made by others, such as putting a service user on a healthy eating diet to lose weight, this has been done in conjunction with others and in the service user’s best interest. The manager spoke of the work needed to ensure each service user has their own bank or building society account and was justifiably proud to have achieved this. The manager recorded that she acts as appointee for four service users. When asked how his money was managed a service user confirmed that: ‘I have my own account and they keep my money safe upstairs for me to use’ Staff are aware that service users have the right to take responsible risks. Risk is well managed and recorded in a risk assessment process which links to goal planning. Risk assessments are carried out in response to individual need and to events which indicate risk management processes are needed. Care management plans include detail of known risks and their agreement to systems to reduce risk. A missing person procedure is in place with a ‘missing person’ form ready in the care file. Personal information about service users is well maintained, staff are expected to follow the principles of confidentiality and data protection. Information is shared only on a need to know basis and wherever practical with the service users agreement. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live a full and varied life which is recognised as their right EVIDENCE: Service users have access to educational and recreational facilities. The location of the home gives easy access to Horsham town centre and to local amenities. On the day of the site visit two service users were at college, another small group were taken out to Shoreham airport for a drive. Staff and a relative spoke with pride of the progress a service user had made since admission including walking through the town to do some shopping which for her was a major achievement. Service users have a schedule of their weekly activities. This includes time at ‘home’ which can be used for appointments such as the hairdresser, doctor or reviews, going out for coffee or lunch, Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 13 helping with the shopping, doing some of their own shopping or helping to keep their room how they would like it. The home has its own transport. A service user confirmed that if he didn’t want to go out on a particular trip he wouldn’t have to but on this occasion was looking forward to going for a drive as ‘I like to get out’. The manager said service users would be encouraged to recognise their responsibility to commitments such as going to college. Staff spoke of good relationships with neighbours and passers by, one service user enjoyed her chats with the neighbours who stopped by when passing. Her father was amazed that she was able to do this and felt it was again due to how she settled she felt in the home. Where it is felt achievable service users are supported to move towards more independent living. Goals are then set to help the service user achieve the necessary skills. When the home was redeveloped a training kitchen was set up where service users develop their cookery skills from deciding a menu, shopping for the ingredients , preparing and serving the meal. A separate activities room is obviously well used. One service user was being assisted by a member of staff to follow his hobby of setting up files of information about soap stars. Another service user had been doing artwork and another was making a card ready for mothers’ day. Relatives can be involved in the service users care if that is the service user’s choice. A relative spoke of how welcome he felt to the home and how all the service users had become ‘friends’. He said he felt reassured that he would be contacted if there were important issues. A service user said how he had made friends by going to college and that he thought he could invite them ‘home’ if he wanted. Some service users make regular visits to their family home. Diversity is very well managed in a non-judgmental and sensitive manner. Service user’s rooms are seen as private and entry to the house is by secure systems. Service users deal with their own mail and are supported as necessary. Cordless phones give availability to be used in private. Staff do the food shopping and cook meals assisted by service users. The menu is planned each week with service users choosing what they would like for the week. An alternative is provided where necessary. There is a good awareness of healthy eating, fresh fruit is readily available and drinks were being made throughout the site visit. Aids to eating are provided and staff are sensitive when assisting someone to eat. A record of food and drink is kept and weight is monitored. Special dietary needs are discussed with relevant professionals. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and care needs are well met, promoting rights, choice and wellbeing but where better medication practices would improve the process. EVIDENCE: Staff are aware of the rights of service users to be treated with dignity and to be respected. This was evident in the way service users were spoken to, had care provided and were supported during meal times. Detail of how this will happen is recorded in the care plans and discussed at handovers and team meetings. Care is taken that not only do service users present themselves as they would wish including clothes preferences, but they will also be encouraged to maintain good personal hygiene. One service user liked a bath twice daily and this was being provided. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 15 Both male and female staff work at the home. Service users spoke and indicated that they had their ‘special’ staff with whom they had a closer relationship, this was well managed balancing professionalism with commitment to service users wellbeing. Care records indicate there are good relationships with local health services. Staff take care that service users’ health needs are monitored and appointments are made with general practitioners and specialists. A system is in place to record detail of such appointments which includes dates of any follow-ups. Mention was made during the site visit that a service user had seen the chiropodist that day. Medication is dispensed mainly through a monitored dosage system (blister packs). Practice needs improvement in that storage and recording of medication isn’t suitable. There is only a single drug trolley to use meaning that current and stock medication and internal and external medication are held together. Medication for individual service users isn’t easily locatable. Medication administration records didn’t reliably tally with the blister packs and items others than medication were stored in the drug trolley. The manager and deputy have received full medication training, other staff have had a half day training through the dispensing pharmacy. It was evident from outcomes that training needs to be reviewed. The manager was very responsive to the problems highlighted, was planning how these would be addressed and had promptly ordered a new medication cupboard. Whilst underpinning practices need improvement, evidence suggests that overall service users are getting medication as directed. A service user confirmed that they were given the right medication at the right time and was happy about the way medication was given to him. Systems are in place to support service users who wish to self medicate or for absence away from the home. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ rights to make comment about the service and be protected from the risks of harm or abuse are promoted. EVIDENCE: A complaint procedure is available and includes detail about both internal and external processes and contacts. A system is in place to record any complaint, investigation and outcomes. The manager said there have been no complaints and none have been received by the commission. Service users are more likely to use their keyworker or support workers in general to express any dissatisfaction and get a satisfactory answer or change to practice, which will often be recorded in the care plan. In this way minor niggles don’t escalate into full blown complaints. One service user is recorded as having an advocate, many have families who may also act on the service users behalf. Staff spoke well of training they receive mentioning most of them have had training in adult protection issues. There is a good awareness of how adult protection is managed including liaising with other professionals whilst supporting the service user and others who may be affected. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have a pleasant, homely environment in which to live but which needs improvements to cleanliness and maintenance. EVIDENCE: The home has now been open for just over two years. It was purpose designed for occupancy for people with disabilities being converted from a former business premises. Staff recognise that there are some areas that with hindsight they would change but overall the home fits in well into the local area and is bright and spacious. The original registration was for 22 service users. Since registration funding for 14 service users was changed to supported living which is now run separately on the first floor leaving the ground floor as the registered home. There is no garden space but the service Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 18 users have a large secure front courtyard to relax in and easy access to Horsham Park nearby. The accommodation is based on a U shape with the central areas being communal space and the two arms being bedrooms, bathroom and storage. Each room is en suite with a washbasin, shower and toilet. There are separate bathrooms if a service user prefers a bath. Each bedroom is large and well personalised. Three service users wanted to ‘show off’ their rooms and others were briefly looked at when making a tour of the building. There is good access for wheelchair users other than into the kitchens. Additional equipment such as grab rails, monitors and bed rails are provided as necessary. The manager said a fire risk assessment has been carried out and sent to West Sussex fire authority. There are no outstanding requirements from the Environmental Health Officer. Some areas of then home look bland and tired and standards of cleanliness need bringing up to scratch. There are no designated cleaning or domestic staff, support workers carry out communal cleaning and are expected to support service users to keep their rooms clean. The manager said that the builders had advised that the walls must not be painted or papered until they had settled. The number of wheelchair users means that there are scrapes and dents to some surfaces. The kitchen areas in particular need attention and presented a risk of cross infection. It is recognised that they are too small for proper use and neither have natural light. From observation and discussion during the site visit staff rightly focus their time of direct work with service users and spend less time on maintaining the environment. A maintenance person visits on request but hasn’t followed up on the manager’s suggestion that he visit more frequently. This has left deficits in responsive maintenance such as the radiator control seen unattached. There are separate laundry facilities and systems are in place to reduce the risks of cross infection from soiled laundry. Staff have protective clothing to use when needed. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have motivated, interested and dedicated staff who provide friendship, care and support. EVIDENCE: One of the key qualities of the service is the commitment, skills and attitude of the staff. All spoken with referred highly to the qualities of the staff, they felt they were really interested in providing service users with a good quality of life, were committed to equal opportunities, worked hard to ensure that time on duty was spent effectively and weren’t ‘clock watchers’ when their shift had finished. Staff understand they are there to work for the benefit of service users, the duties they are expected to perform are recorded in a job description. There is a low staff turnover with a number of staff having worked at the home since it opened. Staff referred verbally and in writing to the good training they Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 20 had. Records of induction were seen. The manager had obtained LDAF training material to use. Staff said that each Tuesday they had an in house training session plus they could access external courses. Out of the 16 support workers, 7 hold NVQ level 2 or above, others are working towards the qualification or plan to start it. The manager is an NVQ assessor. Throughout the site visit service users appeared relaxed and comfortable with the staff on duty. Staff knew how best to communicate with each service user. There was a good balance between encouraging service users with their day and recognising when they needed time and space to themselves. Conversation and activities were inclusive and gave service users time to express themselves. One service user said about a member of staff: ‘he’s my friend, I like him’ A family member said: ‘All the improvements she (a service user) has made, they’re all due to the staff you know, everyone here is wonderful, they couldn’t be better’ Staff spoke of having handovers between shifts and regular team meetings. There was clear evidence of good communication between staff and sharing of core information about service users. A planned staff roster is held. There is no current use of agency staff, in house staff will cover any shortfalls as they prefer someone working with service users who know their needs. Support workers cover all responsibilities in the house including cooking, cleaning, laundry, activities and hands on care and support. Staff know what their duties for the shift will be through handover and the activity schedules. Recruitment records are maintained for each member of staff. Overall recruitment practices ensure that staff are suitable and competent to work at the home. Minor improvements are needed to ensure this happens in the future and that records are complete. Information provided indicated that all staff hold criminal records bureau certificates. Staff are supervised on a day to day basis and there is a system to carry out 1:1 formal supervision and appraisals. Staff said that supervision sessions were useful and two way. Discussion would include training needs, service users and work practices. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed and safe service EVIDENCE: The manager has been in post since the service opened and took a key role in setting up the building, recruiting staff and admitting service users once the home was registered. She has 10 years experience in working in the care sector and evidenced drive and commitment to promoting a good quality of life for each person regardless of their disability. She holds the Advanced Management for Care certificate, City and Guilds 325/3. She ensures that she Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 22 keeps up to date with current practice and maintains her own training and skills development. Staff and relatives spoke highly of her skills saying that there was no ‘them and us’, she was approachable, they all worked as a team yet they knew they could call on her leadership skills when they needed to. All felt well supported by both the manager and deputy. The manager was open to comments about the service and showed a willingness to continue learning , including actively welcoming suggestions from staff to improve the service. Systems are in place to ensure views of the service are obtained and incorporated into practice and planning for the service. Surveys are sent out to families, service users, staff and professionals annually. A sample of those returned commended the service, mentioning the good management and improvement in lives of service users. One social worker praised the staff team for the work carried out in managing the behaviours of a former service user for as long as they did. Whilst formal feedback from each service user is difficult, their needs are built-in into planning for their future. Service user meetings are held regularly. A relative said they were able to air their opinion of the service but had nothing but praise for it. Information provided by the manager and staff said policies were available and accessible to staff within a procedures manual. Not all polices were inspected on this occasion, staff knew detail of key policies and worked in line with their guidance. With some minor deficiencies record keeping was very good. The home has the services of an administrator. The administrator works with the manager to ensure records are current, well maintained and accurate. Support workers also recognise the need to maintain accurate records. There is secure storage for records. Staff said they have had core training and updates where necessary for moving and handling, adult protection, fire safety and food hygiene training, practice seen during the site visit was sound. Staff on duty knew the process for fire evacuation and spoke of fire drills being held. Records showed that fire points were tested weekly. Records of fire practices should routinely record the names of staff attending them. Fire safety equipment servicing is carried out and the manager confirmed that other servicing of supplies and equipment was carried out. The manager said that the owning company are supportive and visit regularly. There was evidence that senior management within the organisation monitor the service and provide feedback to staff at the home. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 23 Incidents and accidents are recorded in the correct manner using the principles of data protection. Incidents affecting the wellbeing of service users are notified to the commission under regulation 37. A current certificate of employers’ liability was seen on display. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 3 2 3 Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13 (2) Requirement Medication must be stored, administered and handled in line with guidelines from the Royal Pharmaceutical society and good practice. This will include that: • There must be sufficient space and facilities to store all medication properly The record of administration must be accurate Medication must be stored at the correct temperature Timescale for action 31/05/07 • • • 2 YA24 YA30 23 (2) (b&d) Staff administering medication must be suitably trained to do so with practice evidencing competence in all processes they carry out. The home must be kept clean and well maintained in that: • Time must be available to ensure that cleaning and maintenance tasks are carried out properly and 31/05/07 Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 26 promptly. • Kitchen cleanliness and storage must be well maintained in manner which reduces the risks of cross infection. 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 YA34 Good Practice Recommendations Certain recruitment practices need tightening up including: • • Wherever possible at least one written reference should be from an employer or professional There should be a better system to obtain and verify written evidence of the reason for leaving previous work with vulnerable people. 2 YA42.2 The record of fire practices should record the names of those staff who attended the practice. Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Westhope Mews DS0000062779.V330516.R01.S.doc Version 5.2 Page 28 - 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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