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Inspection on 10/07/07 for Westhorpe Hall Residential Home

Also see our care home review for Westhorpe Hall Residential Home for more information

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective residents can expect to be properly assessed before being given a place at the home. They can expect to receive the information they require. The home provides a relaxed friendly warm environment with good amenities. Staff are caring and well liked by residents, and spend time talking with residents. Good care plans are in place. Residents can expect to have their health care needs met and to have their medication reviewed annually. Residents can expect the home to welcome and promote family visits and contact. They can be expected to be able to participate in the domestic routine of the home. Residents with dementia can expect to have full access to the whole of the home. Residents can expect formal complaints to be thoroughly investigated and action taken.

What has improved since the last inspection?

Since the last inspection, the home has been registered to care for up to six people with a diagnosis of dementia, and adaptations have been made to accommodate them. The outside are has been improved and section of the garden enclosed. Activities have been developed. A good in house training plan is in place, although it has not yet included infection control.

What the care home could do better:

The home identified some areas in which it could do better in the AQAA it submitted. These included providing life history documents for residents with dementia, and producing a pictorial menu for those with dementia. The home also needs to develop environmental risk assessments for those with dementia, which include the risk of leaving the building unnoticed from any open routes, and also the risk of them entering the kitchen. The environment also need some upgrading in terms of replacement of marked and / or damaged carpets on the landings and in the dining room, and a repair is required to one privacy screen to give proper conditions for one resident. The home has noted the requirement for infection control training for staff; given the omissions in medication recording at this and the previous inspection, updated medication training should also be provided. Medicine administration records must be complete and omissions explored. The most concerning shortfalls are the slow responses the home has made to requirements made by the fire officer and also by CSCI in their last inspection concerning legionella control. Requirements made by the fire officer in respect of upgrading fire doors must be undertaken to ensure residents safety in the event of a fire, and the home must evidence that water temperatures at the boiler are monitored and maintained above 60 degrees Celsius, to reduce the risk of legionella from the water system. Two other health and safety requirements have been made. Emergency lighting must be regularly tested, as per the schedule, to ensure that it will be in working order in the event of a fire in the home. The grounds in the immediate vicinity of the house must be kept free of rubbish to ensure that it is hygienic and free of trip hazards. Finally the home must report any matters as detailed under regulation 37, including the death of any resident to the CSCI.

CARE HOMES FOR OLDER PEOPLE Westhorpe Hall Residential Home Westhorpe Stowmarket Suffolk IP14 4SS Lead Inspector Mary Jeffries Key Unannounced Inspection 10th July 2007 15:45 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 Westhorpe Hall Residential Home DS0000024524.V345849.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. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhorpe Hall Residential Home Address Westhorpe Stowmarket Suffolk IP14 4SS 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) 01449 781691 F/P 01449 781691 Mr K Hunt Ms Virginia R Hunt Ms Virginia R Hunt Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (21) of places Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2006 Brief Description of the Service: Westhorpe Hall is a listed country manor house set in its own grounds and in the village of Westhorpe. It has much character, and has been converted to provide long-term residential care for up to 21 older people. The house is approached by a private drive that crosses an ancient moat. There is car parking and gardens that are accessible to the residents. The main house offers accommodation on ground and first floor, with a modern single storey extension to one side. The ground floor comprises two sitting rooms, dining room, kitchen, office, bathroom, WC’s, and several bedrooms in the newer wing. Six of these are set aside for residents with dementia. A wood-burning stove had recently been installed in the main lounge, replacing the open fire. The first floor is served by two staircases, both fitted with stair lifts, to two separate wings. The remaining bedrooms, two bathrooms and WC are on this level. In total there are 15 single bedrooms and 3 doubles; one of the doubles is being used as a single room. Four of the single rooms are less than ten square metres in size, and one of the double rooms is just under sixteen square metres. The latest revisions to care standards make these rooms sizes acceptable, on the basis that these facilities were registered before the NCSC came into being. On the first floor of the home, there are several changes of floor level, which have to be negotiated, and a number of doorways have raised lips. This poses some limitations on the needs they can meet in terms of residents’ mobility. Fees for the home run £338, to £450. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An Annual Quality Assurance Assessment (AQAA) was provided by the home prior to the inspection. The inspection occurred on an afternoon and early evening in July 2007 and took five hours. The process included a tour of the building, observations of staff and resident interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The inspection was facilitated by the deputy manager. Three residents were tracked, including one with dementia. All of the residents were observed. There was one vacancy in the home at the time of the inspection. What the service does well: Prospective residents can expect to be properly assessed before being given a place at the home. They can expect to receive the information they require. The home provides a relaxed friendly warm environment with good amenities. Staff are caring and well liked by residents, and spend time talking with residents. Good care plans are in place. Residents can expect to have their health care needs met and to have their medication reviewed annually. Residents can expect the home to welcome and promote family visits and contact. They can be expected to be able to participate in the domestic routine of the home. Residents with dementia can expect to have full access to the whole of the home. Residents can expect formal complaints to be thoroughly investigated and action taken. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home identified some areas in which it could do better in the AQAA it submitted. These included providing life history documents for residents with dementia, and producing a pictorial menu for those with dementia. The home also needs to develop environmental risk assessments for those with dementia, which include the risk of leaving the building unnoticed from any open routes, and also the risk of them entering the kitchen. The environment also need some upgrading in terms of replacement of marked and / or damaged carpets on the landings and in the dining room, and a repair is required to one privacy screen to give proper conditions for one resident. The home has noted the requirement for infection control training for staff; given the omissions in medication recording at this and the previous inspection, updated medication training should also be provided. Medicine administration records must be complete and omissions explored. The most concerning shortfalls are the slow responses the home has made to requirements made by the fire officer and also by CSCI in their last inspection concerning legionella control. Requirements made by the fire officer in respect of upgrading fire doors must be undertaken to ensure residents safety in the event of a fire, and the home must evidence that water temperatures at the boiler are monitored and maintained above 60 degrees Celsius, to reduce the risk of legionella from the water system. Two other health and safety requirements have been made. Emergency lighting must be regularly tested, as per the schedule, to ensure that it will be in working order in the event of a fire in the home. The grounds in the immediate vicinity of the house must be kept free of rubbish to ensure that it is hygienic and free of trip hazards. Finally the home must report any matters as detailed under regulation 37, including the death of any resident to the CSCI. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Westhorpe Hall Residential Home DS0000024524.V345849.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 Westhorpe Hall Residential Home DS0000024524.V345849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be assessed prior to admission to the home and for the home to be able to meet their needs. They can expect to receive information about the home. EVIDENCE: The deputy manager advised residents are invited to visit before making a choice to come to the home, but many choose not to and that sometimes a relative comes to have a look around. In that case, the deputy advised, they will visit the resident prior to admission to do the assessment. The AQAA stated that the home obtains a Social Care Services compass assessment prior to admission, and also undertakes a pre-admission assessment of its own. The files of three residents admitted to the home since the last inspection were found to included both of these documents; in one Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 10 case the home had conducted its own assessment over the phone, having already received the Social Care assessment. Two residents spoken with confirmed that they had a Service User Guide. Since the last inspection the home has become registered to care for up to six people with a diagnosis of dementia. The deputy manager confirmed that the home does not offer intermediate treatment. Westhorpe Hall Residential Home DS0000024524.V345849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have a care plan which defines the care they need in various aspects of their lives and for this to be regularly reviewed. They can expect to be treated with respect and dignity. EVIDENCE: Care plans seen had been developed to include a tissue viability assessment and a screening for malnutrition. Care plans were clearly set out and included aims/goals of interventions and support for each area of need. All three residents tracked, and the two recently admitted residents had care plans. The care plans had been regularly reviewed by the residents key worker. One resident who was tracked and who had a diagnosis of dementia did not have a life history, which is important if person centred care is to be given where the resident is acknowledged and responded to the person they have been. They did have a falls risk assessment, having fallen twice in the home, Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 12 but did not have a risk assessment in respect of two aspects of the environment which were seen to pose a potential risk to residents with dementia. These are detailed under environment. Two of the residents tracked require assistance in getting in and out of the bath. Both said that they thought they could have baths when they wanted. One said,” I love a bath, I can have one when I like I think.” The other said that they had two baths a week, but was sure they could have more if they wanted. Residents sitting outside in wheel chairs all had foot plates correctly in place. One resident spoken with advised that they thought the carers had a very nice manner, and that they felt safe in their hands when they were assisted in bathing, using the bath seat. Another said; “ The staff are lovely, they are Bulgarians. Their English wasn’t very good when they came but they have really improved, it hasn’t been a problem. “ Staff were seen relating in a warm and caring manner towards residents during the inspection. Evidence of appointments with a range of health care professionals, including regular blood pressure checks and an appointment at a rheumatology clinic were on file for one of the residents tracked. The deputy manager advised that all of the residents have annual medication review. This was evidenced on the files of two of the three residents tracked; the third had been at the home for less than a year. The AQAA stated that all residents are assessed for their ability to self medicate prior to admission. The medicines cabinet is a locked cabinet in the dining room. The administration of medicines was observed and the carer administering medicines was seen to follow correct procedures, including observing residents when they took the medication given to them. There were a number of gaps in medication records. Controlled drugs were audited and found to be in order. Residents spoken with advised that they were treated with dignity and respect. One confirmed they had a key to their room. Incontinence pads were discretely stored within the home. Westhorpe Hall Residential Home DS0000024524.V345849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of daily life, to be treated as individuals and encouraged to participate in the life of the home to the extent that they are able and wish to do so. Residents with dementia can expect to share their living arrangements with other older people, and all can expect there to be plenty of communal space which allows them to choose their company. EVIDENCE: Some residents were sitting outside of the home, having a cup of tea on the patio area when the inspector arrived. There were garden furniture and bird tables in this area. These residents spoke of particularly enjoying the setting of the home, and all the wildlife that they could see. Most residents were inside; the home has two lounges, one had a television on, the other had a radio on. The atmosphere in both was pleasant, and the television and radio were audible but did not dominate. Both rooms are large, and some residents were sitting in smaller groups relating to each other. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 14 It was not apparent which residents had a dementia diagnosis whist they were mixing with the group. Interactions seen between residents seen were mostly cordial. One resident spoken to said that it could be a problem at times, and they recognised the home had changed, one described how a resident had emptied out their handbag, but felt on reflection it was their own fault, as they hadn’t tucked it away. They advised that some of the newer residents do sit and bicker, but that they knew to keep right out of it. A requirement was made at the last inspection that the activities programme was developed. Some work had been out into this; a relative’s comment included in the last inspection report, “I would like to see, say a quarter of an hour (exercise session) every day, make it a point of value”, had been acted on. One resident tracked on this occasion advised that, “they do exercises with a soft ball, but only for about 15 minutes a day.” The home had developed a weekly activity sheet to record the activities that each resident participated in. These included music and song, twice a week, memory cards and memory books weekly. As noted under health and personal care both residents spoken to in depth advised that the carer staff spent time talking with them, and the activities sheet noted the subjects they would like to talk about in reminiscence and which residents enjoyed topical discussion. Residents help with small tasks in the home to the extent that they are able and that they wish to. One of the residents tracked advised that,“I help with the vegetables and also folding tea towels, it helps my hands.” Other domestic activities listed for some residents include flower arranging and gardening.” One resident tracked said that there was not much to do in the afternoons, another said that they started clay modelling but it dropped off. This resident said that they would like to go to church, although they had not been a regular churchgoer they were a believer and that it had become more important to them as they got older. They said that there were no services at the home, but were aware that arrangements had been made for one resident to attend a local church. This resident said that they had not asked about whether this could be done for them, and the deputy manager confirmed that they did not know this was something the resident would like. This resident confirmed that they had attended the home’s fete, which had been held the previous weekend. The AQAA states that families are welcome at any time. On arriving at the home one of the residents was seen taking a walk in the grounds with a relative. The relative of a recently deceased resident was present at the home; they had supported the home with the care of their spouse and was still welcome to attend each day for a meal at the home where they had come to know many of the other residents. One of the residents tracked advised that the home takes them to see their relative who lives locally; the manager confirmed that as this is the person’s only relative, and they cannot get out at the moment, they make this arrangement. There were two other relatives in Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 15 the home visiting on the afternoon of the inspection, and the atmosphere in the large lounge was congenial. A resident spoken with said that the food was very good, “Mutton for lunch and gorgonzola for tea.” The teatime meal looked very appealing, and was blue cheese and biscuits and strawberries. The AQAA states that whilst it promotes the eating of meals in the communal dining room, residents may choose to eat in other areas of the home. Residents were observed having their tea at various different locations in the home. The daily menu was displayed, in written form. The main meal on the day of the inspection had been chicken and leek soup or fruit cocktail, lambs chops, and jam pudding with custard. A list of alternative choices always available was also displayed, these included scampi, pizza, haddock lasagne, and toad in the hole. The menu was not available in picture form, which would assist those with dementia make choices. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to have access to a clear complaints policy, to feel able to complain, and for these to be thoroughly dealt with. They may not however feel they get clear feed back on small concerns raised. EVIDENCE: The Statement of Purpose and Service Users’ Guide clearly explain the complaints procedure. The AQAA stated that the home had received one complaint in the last twelve months, that it had been dealt with within 28 days, and that it had been upheld. A record of complaints is maintained in the office. In addition to the complaint recorded, this included a verbal complaint, and another from a member of staff. These had been dealt with thoroughly, and the disciplinary procedure had been used where staff ad been found to be at fault. One resident asked how they would go about making a complaint of they responded: “I don’t think there is anything I’m not happy with, I like it here.” Another resident said that “when I make a suggestion or make a complaint you never hear about it again.” They clarified that they had not made any written complaints and were speaking about “little niggles.” Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 17 Complaints information is available to residents in their Service User Guides. The whistle blowing policy is displayed in the home. Staff received training on the protection of vulnerable adults in April 2006. The deputy manager was aware of the correct referral routes for any suspected abuse. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect a homely and attractive environment, but cannot be assured that it will be maintained to minimize hazards at all times. EVIDENCE: The home is set in a very rural location, and there is a long driveway down to the road. The fencing around the moat was inspected and found to be in good order. The grounds around the home were substantially clearer than at the last inspection however there was some coal, a coalscuttle and a dustpan lying around and a dead bird. There was also a cracked plastic tabletop flat on he ground which represented a tripping hazard. This was moved when pointed out. The deputy was asked whose responsibility it was to check the external area, they advised that although there is a handy man who looks after the outside they only attend monthly and this was not a designated responsibility to do daily checks, everyone had a responsibility. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 19 The outside space is good; a number of residents were sitting in the garden when the inspector arrived. Since the last inspection a second patio area has been developed which can be accessed from the television lounge by a ramp. Westhorpe Hall offers a very homely environment. There are three main communal areas within the home, a large lounge with a wood-burning fire, a smaller, but substantial television lounge and the dining area. The kitchen leads into the dining room, and some residents with food preparation. This link with the kitchen is homely, however the kitchen was accessible at points during the afternoon when there were no staff in it. There were potential risks for residents with dementia, or example a knife block with sharp knives was accessible. The carpet in the dining room had been cleaned and but was in need of a further clean. The upstairs carpet had tape in several areas on thresholds to rooms and was also starting to fray along the edges. The home has integrated the care for those with dementia into the general care within the home. There are no locked areas: the bedrooms for residents with dementia are all within one area, beyond a fire door in the corridor, which is on a self-closing device and was open during the day, giving full access to the rest of the home. The six rooms for dementia care and the corridor to these rooms were well decorated. Work had started on decorating the adjoining corridor. The doors to individual rooms for those with dementia had meaningful pictures on them to help these people identify their own rooms. All doors to outside from this corridor and from the room’s French windows and from the room doors to this corridor have been put on sensors linked to nurse call system so staff are alerted if residents leave their rooms. Staff were seen to respond to these as they were sounded throughout the day. An area of the grounds outside of this corridor had been fenced, but was not secure. A carer advised that one of the carers on shifts focuses on this part of the home, and remain alert to the indications that someone has left the house. Two rooms sited along the same corridor, but before the fire door, are for older people without dementia. These rooms also had French windows to the grounds, and one of them was open during the afternoon. This room was not locked, and it would be possible for a resident with dementia to leave the building through route without being noticed. The deputy manager advised that they knew the residents well and none of the current residents would be likely to do this, but that there were not specific risk assessments in place. A number of bedrooms were seen; these were clean and personalised. In one shared room the privacy screen did not offer full privacy for residents. The deputy manager advised that this was waiting to be fixed. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 20 The laundry was seen to be clean and tidy and to be of an acceptable standard. A member of staff confirmed soiled laundry was transported in tied black bags, and never brought into the food preparation or dining areas. A mop was seen stored with its head down, and damp in a bucket; this is not good infection control practice. Communal bathrooms were seen to be organised and clean. Paper towels and liquid soap was provided however soap and material towels were found in communal bathrooms. The AQAA states that the home plans to renovate the two upstairs bathrooms, and this will provide an additional shower and two assisted baths. Bathrooms seen were clean and had appropriate paper towels and liquid soap; the deputy manager advised that this was something she had to remind staff about. The home plans to site a log cabin for residents use in the grounds. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents can expect to have enough staff on duty to meet their needs, and for these staff to relate to them well and with kindness. EVIDENCE: The AQAA states that the daily staff compliment is two carers and a team leader on duty between 7am and 10pm. Additionally, a deputy manager works five days a week and a Registered Manager two days a week. There is a cook on duty between 8am and 5.30 pm, and 20 hrs per week domestic support. There are two waking night staff between ten pm and 7 am. The deputy advised that there were always three on a shift during the day, and that if they were short of carer that they themselves did a care shift. The staffing rota was seen and this was confirmed. The deputy was scheduled to work the late shift on the day of the inspection and also the next day. A member of staff spoken to advised that they always had three on duty and that it made working at the home much better, in particular if two staff were involved in any sort of crisis this left another member of staff to take an overview. Staff appeared busy throughout the afternoon, but everyone’s needs were being attended to and staff were responding o any indication by the alarms in place that someone had gone outside, going to check who this was. Residents Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 22 spoke well of the carers, particularly the overseas carers and were appreciative of their manner. The deputy did not have a staff list, and had not retained a copy of the information they had sent to the recent Skills for Care Survey, which is assessing levels of training in homes. They gave verbal details of fifteen care staff and two relief carers; five had at least level 2 NVQ, but one was on longterm leave. They advised that they were waiting to employ three new staff Subject to satisfactory references and checks, but that none of these had an NVQ. The deputy had identified two staff who were willing o be put forward to undertake their NVQ. The deputy advised that there was not necessarily a carer with an NVQ qualification on a shift, but that they were on call for support. The AQAA states that the home has made it a requirement that new team leaders have an NVQ2. This was discussed with the deputy manager who advised that this is hoped to be an incentive. Two files of the most recently appointed carers were checked. These contained references and Criminal Record Bureau checks undertaken prior to them commencing work at the home. There were also details of proper recruitment processes and proof of identity on file. There was also evidence of induction on these two workers files. Staff files also contained evidence of recent training on fire awareness, health and safety, manual handling, incontinence dementia and malnutrition screening. H & S. The deputy manager is trained to provide manual handling training and they advised that they go to yearly updates on this. The AQAA stated that staff had not received training in infection control, and that this was planned to take place within the next twelve months. The deputy advised that this had not yet taken place. Apart from a staff update on the new monitored dosage system in place, there had been no medication training since Autumn 2005. The deputy manager advised that this was not scheduled yet as they were trying to get a date from the pharmacist but had not done. There are shortfalls in medication recording noted elsewhere in this report. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect the homes management to have a good knowledge of them, and to consider their comfort and well being in the running of the home. They cannot be assured however, that they will receive good formal communication on matters they have raised. Residents cannot be assured that their health and safety is fully protected. EVIDENCE: The Service User Guide states that the Registered Manager holds a Diploma In Care Services, and the Deputy Manager holds the Registered Managers Award. Evidence of these qualifications has been seen a previous inspections. The deputy manager had a good knowledge of all residents needs; they advised that when there was an unexpected staff absence they would work on the floor, and that this could be daytime of nighttime. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 24 The AQAA states that the Registered Manager works two days a week, and that the deputy manager works five days, this being in addition to the three care staff. As noted under the staffing section, the deputy sometimes works on a care shift. There is no administrator. In the AQAA, it was stated that, “ We hold regular service user meetings, which are chaired by the deputy manager and minuted, at these meetings we ask for the views and feelings of the service users as well as advising them of any plans we have for the home. The deputy manager allows time at the end of the meeting in case any individual attending wishes to raise issue they are not comfortable doing in an open meeting.” The last minutes available of a residents meeting were for Summer 2006; these were displayed in the home. The deputy manager advised that they had not got round to doing the last two sets of minutes, but that only one resident had attended. The home does hold some monies for residents but the deputy manager did not have access to this. Appropriate records were in place. The home does not have a “shop”. One resident was involved in starting a service for small items to be purchased within the home, but advised stocks had been allowed to run low, although they had brought this to the attention of the management. The resident was asked how they otherwise obtain things like toiletries; they advised that they had a friend they could ask, but that they did not like to inconvenience them too much and found this a little difficult. There are no very local shops. One resident spoken with said; “There is a general slackness, the owners ……… only come one day a week, I feel they could do with a full time administrator.” The CSCI had not received notifications of any deaths of residents within the last twelve months; however, the AQAA provided by the home stated that there had been 3 deaths in the home and three in hospital in this period. The home had not conducted a residents survey since May 2006. The deputy manager advised that they had devised an as and when quality audit, and that one shift had been looked at in detail, but that the results had not yet been written up. The home did, however, give a number of examples of changes they had made in response to residents wishes, for example making the greenhouse more accessible (on a risk assessed basis.) A member of staff spoken with advised that they had regular supervision. There was evidence of regular supervision on two staff files recorded. Two members of staff had received warnings under the disciplinary system; this was also appropriately recorded. The homes Certificate of Registration and public Liability insurance certificate were displayed. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 25 A critical control point hazard analysis was in place for the kitchen. Records showed that the fire alarm was tested regularly, and a resident spoken with confirmed that they were aware of this, but emergency lighting tests had not been carried out since January 2007. Two more serious health and safety matters, which had not been dealt with in a timely way, were identified. At the previous inspection, a requirement had been made that the home must evidence that water temperatures at the boiler are monitored and maintained above 60 degrees Celsius. The home has subsequently commissioned a report on this matter, which had been forwarded to the CSCI. On this occasion, however, the home had no evidence to show that the recommendations of a contractors report into the risk of legionella had been acted upon, and no evidence of monitoring systems being put into place. This report had advised that urgent remedial work was required to bring the storage cistern in line with water regulations. An immediate requirement was made, and the home has subsequently responded by providing evidence of implementing regular basin flushing and shower head cleaning, and also that they have commissioned works to have remedial works carried out to the storage tanks and pipe work as advised by the contractors with the original report. In November 2006, the fire officer wrote to the home, stating that in order to make the means of escape adequate, high Melting point hinges, intumescent strips and stronger closures were required on fire doors. The AQAA stated, “We are continuing our planned programme for the replacement of some internal fire doors.” This was discussed with the deputy manager, who advised that the two most urgent doors had been replaced, but that they were planning to replace all older doors upstairs s to comply with this, but did not yet have a date booked for this work to be done. Although the fire officer gave no timescale, this deficiency now requires addressing quickly. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 2 X 2 X X 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 X 3 2 1 Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 27 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 OP7 OP22 Regulation 13(4) Requirement Timescale for action 15/08/07 2. OP9 3. OP10 4. OP19 5. OP25 OP38 Residents with dementia must have a risk assessment on the possibility of them leaving the building unnoticed through other residents’ bedrooms, for entering the kitchen and for any other environmental hazards to ensure that their ability to live with any hazards in the home has been assessed and addressed. 13(2) MARs sheets must be complete, and any omissions explored. This is a repeat requirement from 18/07/06. 12(4(a) Privacy screens in shared bedrooms must be fixed so that residents are afforded privacy to dress and wash. 23(2)(d) Carpets must be maintained to a good standard to maintain residents pride and dignity in their home and to ensure they are not a tripping hazard. 13(4)(a)(c The home must evidence that ) water temperatures at the boiler are monitored and maintained above 60 degrees Celsius, to reduce the risk of legionella from the water system. This is a DS0000024524.V345849.R01.S.doc 10/07/07 15/08/07 30/09/07 10/07/07 Westhorpe Hall Residential Home Version 5.2 Page 28 6. OP30 12(1)(a) 7. OP37 37 8. OP38 23(2)(o) 9. OP38 13(4) 10. OP38 23(4)(a) (b)(c) repeat requirement from 18/07/06. Staff must be sufficiently trained in medication administration and infection control, so that residents health and safety and welfare is fully protected. The CSCI must be notified of events within the home in accordance with regulation 37, to ensure that the home may be effectively monitored. The grounds in the immediate vicinity of the house must be kept free of rubbish to ensure that it is hygienic and free of trip hazards. This is a repeat requirement from the inspection of 18/07/06. Emergency lighting must be regularly tested, as per the schedule, to ensure that it will be in working order in the event of a fire in the home. Requirements made by the fire officer in respect to upgrading fire doors must be undertaken to ensure residents safety in the event of a fire. 30/09/07 07/08/07 07/08/07 10/07/07 15/09/07 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 2. 3. 4. Refer to Standard OP7 OP12 OP15 OP28 Good Practice Recommendations Life histories should be included on care plans for those people with dementia, as is intended. Opportunities for residents to meet their spiritual needs should be promoted. The daily menu should be available in picture form for residents with dementia. The home should continue to develop the percentage of DS0000024524.V345849.R01.S.doc Version 5.2 Page 29 Westhorpe Hall Residential Home 5. OP32 staff with NVQ 2. Meetings for residents and staff should occur regularly. Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Westhorpe Hall Residential Home DS0000024524.V345849.R01.S.doc Version 5.2 Page 31 - 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. 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