Inspection on 27/01/06 for Westhope Mews

This inspection was carried out on 27th January 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westhope Mews 14/03/07

Similar services:

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 S Rodgers Unannounced Inspection 27th January 2006 09:30 Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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.V281463.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V281463.R01.S.doc Version 5.1 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 21 Category(ies) of Learning disability (21), Physical disability (21) registration, with number of places Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Westhope Mews is registered to provide care for up to twenty-one residents with Learning and Physical Disabilities. The building is a detached premises situated in the town centre of Horsham. Local amenities such as shops, leisure centres and public transport are nearby. Accommodation is provided on ground and first floor levels. The home has been divided into four separate units, with each bedroom having its own en-suite facilities. Six bedrooms on the ground floor can accommodate people who are wheel chair users. Communal space comprises of a lounge and dining room in each unit and a sensory room, an activity room and two multi purpose rooms. 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. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 hours. Westhope Mews is a new service therefore planning for this inspection was based on reviewing records such as the Statement of Purpose, Service User Guide, the registration documentation and general correspondence. During the course of the inspection the inspector toured the home and reviewed records. The two residents residing at the home were both spoken with at this inspection. One resident told the inspector “It’s great here, the staff are great, how they put up with my jokes I will never understand”, further comments will be included in the main body of the report. Staff on duty at the time of this inspection appeared knowledgeable with regards the needs of the residents. The interactions between residents and staff were also observed and were found to be relaxed and confident. During the morning staff were undertaking activities with both residents, there was a jovial and calm atmosphere within the home. Although the majority of staff were spoken with informally, one new staff member was spoken with individually in order to gain a sense of the support she receives to enable her to carry out their duties. Since registration the organisation has made an application to de register fourteen beds on the first floor and provide supported living accommodation and maintain registration for seven beds on the ground floor. One requirement has been identified at this inspection. The registered manager must supply an action plan that details how the requirements made in this report will be met. The action plan must be sent to the commission by the 28 February 2006. What the service does well: The service offers residents the opportunity to develop individual lifestyles within a residential setting taking into account individual abilities, aims and aspirations. Residents are offered a wide range of activities and are encouraged and enabled to access the local community. Care plans are clear Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 6 and concise and assist staff to deliver a consistent standard of care to each resident. Risk assessments are in place for any identified risk associated with care practices and activities undertaken by staff and residents. The staff team were interacting with residents in a relaxed and confident manner. 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. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, Prospective residents and/or their representatives have access to information that enables them to make an informed choice about moving into the home. Pre admission assessments are carried out prior to moving into the home in order to ensure that the home can meet their needs. Written contracts/statement of terms and conditions are provided. EVIDENCE: Prior to moving into the home prospective residents and/or their relatives receive a copy of the homes Statement of Purpose and Service User Guide. These documents clearly inform prospective residents of the services provided. Written pre admission assessments were available and demonstrated that resident’s health, personal and social needs are assessed. Copies of the homes assessment and the Care Management Assessment were available at this inspection. A sample written contact was reviewed. They clearly identify rooms occupied, overall care and services, fees payable, additional services to be paid for over Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 9 and above those included in the fee, rights and obligations of resident and registered provider and terms and conditions of residency. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7.9 Residents assessed needs and personal goals are reflected in care plans. Service users are assisted to make decisions about their own lives. Residents are supported to take risks. EVIDENCE: Care plans are in place. Care plans are based on the homes own assessment, the Care Management assessment and residents preferences on how they wish their care to be delivered. There is clear evidence that residents are involved in the development of their own care plans. Residents confirmed when asked that they are able to make decisions about their own life. One resident said, “ It’s great here you have a free choice”. The care planning documentation clearly demonstrates that residents are encouraged to identify their aims and aspirations in order that the staff can assist them to achieve their goals. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 11 Risk assessments are undertaken on all activities and any identified risk is assessed and action plans are put in place to minimise risk to residents and staff Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15,16,17 Residents are offered and take part in appropriate leisure activities and access the local community. Residents are supported to maintain appropriate relationships. The rights of residents are respected. Residents are offered a well-balanced and varied diet. EVIDENCE: Residents spoken with and individual activity plans demonstrate that residents are able to take part in age, peer and culturally appropriate activities. Activities include, college/educational courses, shopping, bowling, going to the cinema, swimming and going for walks. The home also has its own activities room with a selection of games etc, and a sensory room. One resident said, “ I like going for walks and watching the T.V and videos”. Both Residents spoken with said that they like living at Westhope Mews. Residents are enabled to maintain contact with family and friends, the Statement of Purpose and Service User Guide informs of the visiting Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 13 arrangements. One resident told the inspector that she speaks with her parents via the telephone on a regular basis and that they visit the home each week and stay for tea. Residents are also encouraged to invite their friends to the home for tea. Records indicate that resident rights and responsibilities are recognised, i.e. residents are able to decide if they want to access local amenities and activities. Records of meals provided indicate that a well balanced diet is being offered. Both residents confirmed that they like the meals provided and are consulted regularly and assist with planning the menus. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Resident’s receive personal support in a manner most suited to their individually assessed needs. The health and emotional needs of residents are met. Appropriate systems are in place for dealing with medicines. EVIDENCE: Records indicate and residents confirmed that they receive support in the way in which they prefer. Residents confirmed and the inspector observed that intimate care is provided in the appropriate manner i.e. doors closed when personal care task undertaken. One resident told the inspector that “staff also help to arrange hair appointments either in house or out in the community” depending on preference. All residents are registered with a GP. Records of visits of health professionals are recorded. Records also indicate that residents have access to other paramedical services such as opticians, chiropodists and dentists. Residents also have access to the Community Team for People with Learning Disabilities. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 15 The home has an agreement with a local pharmacy. The monitored dosage system is used. Appropriate systems are in place for the receipt, recording, administration and disposal of medication. Mrs Kelly told the inspector that staffs that administer medication have received training. There are also procedures and forms to be completed should a resident go away for a short break or should there be an error in administration of medication. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 A complaints procedure is in place. Systems are in place to protect residents from abuse, neglect and self–harm. EVIDENCE: The homes complaints procedure clearly advises residents and/or their relatives of their right to complain. The procedure states each state of the complaint process and timescales by which the complaint will be dealt with. Residents spoken with told the inspector that they felt able to talk with all staff about any concerns that they may have. The home has a policy and procedure in place that informs staff of action to take should they suspect abuse of a resident. Mrs Kelly confirmed that 5 out of 7 staff have received Adult Protection training. The one staff member spoken with confirmed that she will soon be covering Adult Protection procedures in the Learning Disabilities Award Framework induction training. Both the manager and the staff member spoken with gave a good account of action to take should they suspect abuse of a resident. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Accommodation is appropriate to the needs of the residents. The home is clean and hygienic. EVIDENCE: The property has recently been renovated and refurbished. The home is comfortable, bright and cheerful. The rooms accommodate by residents appeared homely and welcoming. Bedrooms can be individually furnished with resident’s own belongings. When touring the building it was noted that not all rooms have been furnished. Mrs Kelly advised the inspector that the reason for this is that if a resident wants to furnish their own room with their own belongings they can, however should they not have their own furniture or they need specialised equipment furniture will be provided by the providers. Fire safety systems are in place. From touring the home the inspector was able to see that the standard of cleanliness was of a high standard. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Residents are supported by competent staff. A recruitment procedure is in place. Staff receive training appropriate to the needs of the client group. EVIDENCE: All staff at Westhope Mews are undertaking induction training linked with the Learning Disability Award Framework. Seven carers are employed by the home. Four staff have obtained NVQ qualifications. Duty rotas indicate that an appropriate skill mix of staff are on duty. Mrs Kelly confirmed and records evidenced that training needs are assessed during supervision sessions. The management does follow a recruitment procedure. All new staff complete an application form. Prospective staff are invited for an initial interview, if successful a second interview is offered. A Criminal Records Bureau and Protection of Vulnerable Adults check is undertaken and references sought. However when reviewing recruitment records it was noted that one of the two references required to be kept on file was missing. The management must ensure that all records on all new staff are received prior to commencement of employment. Training records indicate that staff receive training appropriate to the needs of residents. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Resident’s benefit from a well run home. The health and safety of residents is promoted. EVIDENCE: Mrs Kelly holds a certificate in Advanced Management for Care City and Guilds 325/3 and hold and NVQ Assessors certificate. She has worked within the care sector for approximately 8 years. The records seen at this inspection were of a good quality and were in good order. Residents and staff spoken with told the inspector that they feel supported by Mrs Kelly. Standard 39 has not been fully assessed at this inspection, as this is a new registration. However residents did confirm that they felt their views are taken into consideration. Staff receive training in safe working practices, some of these areas are being covered in the induction training. Although this is a new service systems are in place to carry out maintenance checks on boilers, electrical systems etc. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 20 Risk assessments are carried out on safe working practices such as manual handling and significant findings of risk are recorded. All staff receive induction training in line with the Skill for Care requirements. Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 3 X Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 22 NA 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 YA34 Regulation 17 Sch 4 6 (a) Requirement Records required to be kept by regulation must be available for inspection. Timescale for action 28/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 23 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 Westhope Mews DS0000062779.V281463.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!