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Inspection on 18/07/06 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 18th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

The majority of residents enjoy a good quality of daily life. Food is wholesome, well presented, and enjoyed by residents. Residents are treated with respect and as individuals, and encouraged to pursue individual interests. Relatives are welcomed into he home. Resident`s health care needs are well met. Staff recruitment and supervision is to a good standard.

What has improved since the last inspection?

The Service User`s Guide had been amended to include terms and conditions and a copy of the last inspection report. A policy for pressure area risk assessment and care had been put into place, and training given on it. The home is more than half way through an exercise to revise service user`s plans, to include Waterlow tissue viability risk assessments for all and a new format which included goals for each area of care. The laundry floor had been replaced, and a floor in one residents bedroom had been screeded and then re-carpeted, there were no unpleasant odours in the home. A critical control point hazard analysis had been put in place to minimise risks in food production.

What the care home could do better:

Any omissions in Medical Records administration must be addressed fully, and records must be complete. Some aspects of the environment now require attention and redecoration. The environment needs to be regularly checked for hazards, and these must be eliminated or reduced as a far as possible. The social activity programme needs to be developed and consistently implemented. The home needs to increase the number of carers with NVQ2. The review and re formatting of care plans needs to be completed.

CARE HOMES FOR OLDER PEOPLE Westhorpe Hall Residential Home Westhorpe Stowmarket Suffolk IP14 4SS Lead Inspector Mary Jeffries Unannounced Inspection 18th July 2006 14:45 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.V304451.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.V304451.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 01449 781691 Mr K Hunt Ms Virginia R Hunt Ms Virginia R Hunt Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 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. 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, which are a tripping hazard. This poses some limitations on the needs they can meet in terms of residents’ mobility. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was facilitated by the deputy manager. Two carers were spoken with. The inspection took five and a quarter hours. A completed pre-inspection questionnaire was provided by the home prior to The inspection, and ten residents completed and returned CSCI “Have you say” comment forms. There were seventeen residents residing at the home at the time of the inspection, including one who was on a respite placement. One group of three residents and another of two other residents were spoken with, and two residents were spoken with individually in more depth. A relative was also spoken with. The home had made an application for a major variation, and this was discussed with the deputy manager. What the service does well: What has improved since the last inspection? The Service User’s Guide had been amended to include terms and conditions and a copy of the last inspection report. A policy for pressure area risk assessment and care had been put into place, and training given on it. The home is more than half way through an exercise to revise service user’s plans, to include Waterlow tissue viability risk assessments for all and a new format which included goals for each area of care. The laundry floor had been replaced, and a floor in one residents bedroom had been screeded and then re-carpeted, there were no unpleasant odours in the home. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 6 A critical control point hazard analysis had been put in place to minimise risks in food production. 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. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 7 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.V304451.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,6 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents have the information they need to make an informed choice of home, and the home will be able to meet their needs. EVIDENCE: A revised Statement of Purpose was submitted to the CSCI prior to the inspection, accompanying an application for a major variation to enable the home to provide care for a number of residents with a diagnosis of dementia. This was discussed at the inspection with the deputy manager, who advised that consultation with residents and their representatives had still to take place. The deputy manager advised that the terms and conditions and reference to the availability of the last inspection report were now within the Service User Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 9 Guide. A resident spoken with showed they had their own copy of this document, and this did include both items. The home provided information on current charges, which are between £331 and £388 per week. The deputy manager confirmed that none of the current residents had a diagnosis of dementia. The file of the most recently admitted resident was inspected and contained a pre-admission assessment, which the deputy explained they had undertaken when they went to visit the resident. They advised that if the prospective resident cannot come to the home to visit, then the home visits them to assess prior to admission. The deputy advised that they do sometimes have an emergency admission, but that they also always have a Compass single assessment. In these instances, if it is not possible to visit then they telephone to get further details prior to admission. The file inspected contained an assessment of the suitability of the resident’s room, and the residents contract included a room number. The assessment was signed by the resident and their son. The deputy manager confirmed that the home did not provide Intermediate Care. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents can expect to have their health needs clearly defined and met, and that pressure area care will be provided in line with a written policy. EVIDENCE: The deputy manager advised that they were updating care plans to include clear goals and water low pressure area risk assessments, and that they has so far completed this exercise for ten of the seventeen residents only. This was evidenced in care plans inspected. Three care plans were inspected and the residents were tracked. All plans had been regularly reviewed in house, and occasional reviews with social care were also documented. A policy on pressure area care was in place, and training in the use of the Waterlow tissue viability risk assessment had been given to staff. The deputy confirmed information in the pre inspection questionnaire that one resident Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 11 only had a pressure area; this residents record were inspected. The district nurse was attending twice weekly. A relative spoken with advised that their spouse had had a stroke during the winter months, and that the doctor had preferred them to stay at the home, which they were happy with. Resident’s care plans inspected included 3 entries a day on daily notes; these focused on physical well being, but also included records of time spent talking with residents. Resident’s records included visits from chiropodist, lists of G.P.’s involvement and eye clinic appointments. One resident whose behaviour had been challenging for a period recently had had blood tests undertaken. This had proved negative and they had been referred for a mental health assessment, following a full review which included the social worker. One of the residents tracked had bedsides in place; there was a risk assessment signed by the residents G.P. and relatives to support this use. A resident spoken with advised that if you need to see the doctor, “staff phone up and one of them takes you down there.” Another explained; “The doctor is here nearly every Wednesday, but if you had an emergency they will call him in.” One resident had a risk assessment for self-administration of medication in place. 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. The carer administering medication advised that the last update they had received was by Boots, in 2005. The deputy manager advised that the Registered Manager does a stock check every week. Medical Administration sheets (MAR) all contained photographs. Four gaps were found in the MAR sheets inspected. Three of these were on the same shift. The deputy did not know whether this had been picked up individually with the member of staff responsible; they advised that they had not been asked to do so. During the day, a pot of Sudo cream was found in one of the communal toilets. The deputy manager confirmed that this belonged to one particular resident and it was immediately removed. Residents spoken to advised that they were treated with dignity and respect. One confirmed they had a key to their room. They said of the carer’s; “ they always knock before they come in, I get a cup of tea brought to me every morning, and they knock before they come in. It’s a nice start to the day.” This resident went on to say, “You can go to be when you like. You can eat in your room but you are encouraged to eat with the others. (A while a go) I was Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 12 ill for a couple of weeks; I ate in my room then. The routine of life is nice, they always offer you a birthday party but you don’t have to have one, I’m not into parties. A relative spoke with said, “ They have lovely birthdays here, when it was mine they brought a little cake with one candle.” Photographs of the birthday celebrations were seen; tables were decorated with flowers and a “ good spread” was on display. Incontinence pads were discretely stored within the home. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality in this outcome area is good. This judgment 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 to enjoy good food in a pleasant environment. Those who would benefit from organised activities, for example those without relatives or without very much personal motivation, may find these lacking. EVIDENCE: A number of residents were sitting, under shade, in the garden on the day of the inspection. Ice-lollies were brought round and offered to residents. 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. Ten “Have your say” surveys were returned by residents prior to the inspection; one resident commented that there was very little in the way of social activities, nine indicated that they were satisfied with this area of life. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 14 On the notice board, an exercise session was advertised, but by early evening this hadn’t happened. One resident confirmed that they hadn’t had any activity that day. This resident said that they go for a walk in the round every day. This resident also confirmed that they did the notes for the resident’s meeting, but that this had not taken place recently. Another resident said, “ It is a bit lacking on the social side.” They went on to explain, I think the carers think their job is just looking after people’s physical health, getting them up, dealing with tablets……I talk to one or two. There have been no exercises today, I do some on my own, I have every day for years. I would like to see, say a quarter of an hour every day, make it a point of value.” The deputy manager advised that the home was trying to develop a set routine of social activities for the week. The home had recently held a fete which residents confirmed they had assisted with. One resident said that they particularly liked the location of the home: “ we often see animals and wildlife.” There were several families of baby ducks on the pond at the time of the inspection. Another of the residents attends the local church; the deputy manager explained that the home will take her, and the church community are very good in ensuring that the resident gets a lift back. The manager advised that all residents had been offered this but that there was little interest. One spoken with confirmed this was the case, they were not interested. The deputy manger advised that the menu is developed every day, and residents asked their preference on the day. They advised that the day’s menu is usually written up, but it was not at the time of the inspection. One resident spoken with said that they had forgotten whet they had for dinner, but that it was nice. They said that “ The food is very good here”, that they usually had meat, potatoes and vegetables, and the vegetables were always “nice and fresh.” Another said that, “ The food is very good, we have a good cook.” On the day of the inspection the main choice was chicken and leek soup, sausage toad with new potatoes, jelly and ice cream or strawberries and cream. The list of meals provided during the last week was seen and contained a good range of cooked meals, including quiche, liver and bacon, fish and chicken casserole, with a roast on the Sunday. A range of alternatives was available at all times. One resident was recorded as frequently choosing the alternative, which included scampi, lasagne, and fish cakes. A list of food needs for individual residents, for e.g. a soft diet, and preferences was kept. A cooked breakfast was offered every day. The cook had a copy of the CSCI information pack and bulletin regarding meals in care homes. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 15 There was a pleasant atmosphere in the dining rooms at the mealtime on the day of the inspection. One relative was present assisting with feeding their spouse; they confirmed that they wanted to do this and that the home always provided them with a meal. They described it as a “ home from home.” One resident spoken to who had previously had an ordinary wheelchair, had been assisted by the deputy manager to purchase a small, compact motorised wheelchair. They had purchased this themselves. The resident explained how this had given them a new lease of life, and how instead of waiting to be moved, they were able to take themselves to their room and move around the home. They were observed using this along the corridors and managed the chair very well. Westhorpe Hall Residential Home DS0000024524.V304451.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents can expect to have access to a clear complaints policy and feel able to complain. EVIDENCE: The Pre inspection questionnaire indicated that the home had not received any complaints in the last twelve months. The homes’ complaints log was seen and this was confirmed. The complaints policy is fully stated in the Service User’s Guide. One resident pointed out that the policy on how to complain is in this. A resident spoken with said that they hadn’t had to make a complaint yet. They said that they would speak to the “high one” if they had to make a complaint, and that they thought they probably would be listened to. They were asked what they based their opinion on, and they commented, “ It’s just the way they are.” Another very articulate resident stated, “ there’s nothing really to complain about, I’m very well looked after. The carer’s are all very good; I never have to want for anything”. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 17 There had been no safeguarding referrals in the last twelve months, but staff had received training in the protection of vulnerable adults in April. Records were seen. Westhorpe Hall Residential Home DS0000024524.V304451.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,25,26 The quality in this outcome area is adequate. This judgment 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: There were no unpleasant odours in the home. A room that had previously had a lingering odour was inspected and found to be odour free; documentation was seen evidencing action undertaken to provide a screed to the floor below the carpet. The carpet in the dining room, however, had a large dirty patch. The home has many entrances and bedrooms are on two floors. In two areas, stripped tape that had been laid down to mark potential trip hazards was coming unstuck and was crumpled. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 19 There was a new large fish tank in the sitting area, which residents advised had been purchased with the proceeds of the recent fete. A resident’s room was seen to be clean, attractively decorated and personalised. Some of the decorating in corridors, for example radiator covers was beginning to look tatty and worn, and needed attention. The bottom of some doors to individual rooms were badly scuffed. A recommendation was made at the previous inspection that the recommendations form the Occupational Therapist report that the home commissioned should be carried out. The deputy manager was unable to provide the report to enable the inspector to establish whether this had been completed. The laundry floor had been replaced to a good standard. Fencing around the pond was inspected and found to be in good repair, but there was some rubbish in a corner of the courtyard outside of the laundry door, which was accessible to residents. The second lounge has a French window into the garden, and there were a number of hazards in this vicinity. A plant was trailing across the French window, a cable which went below the French window had loose fixings, and there was a large pile of ashes in this area. There were also a couple of garden tools left lying near by. The deputy manager advised that the handyman was on holiday. The Patio on this side of the house is somewhat uneven, particularly as it meets the lawn. The deputy advised that the home is planning to re-do this area. There was a pile of towels stored in one of the communal bathrooms. The pre-inspection questionnaire provided by the home did not provide information on temperature checking of hot water for legionnella control. The deputy manager advised that they had no knowledge of any checks taken in respect of water temperatures at the boiler. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents can expect to be protected by staff recruitment policies and training. EVIDENCE: Two staff were on duty throughout the day; with a shift change at 5.30pm. One of the staff scheduled to work was on the training course being held that day, and another was covering their shift. The deputy manager lives on site and is available to staff at all times. The call bell was not heard often during the inspection. At 4.15 it was sounded and responded to within two rings. At teatime it was sounded and it took longer to respond to, but the home was adequately staffed. The pre inspection questionnaire submitted by the home stated that 34 of staff held NVQ2. One of these also held an NVQ 3. The deputy manager advised that they were trying to get more staff to commence the NVQ. Records of a skills for care induction training course provided for three new staff were seen. Fire training and manual handling records were also seen to be up to date. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 21 The home had a policy on the use of volunteers which covered normal recruitment practices. The deputy manager advised that there was currently one volunteer on their books. This workers Criminal Record Bureau check was seen to be in place. They also had an application form references and ID on file. Two other staff recruitment files were seen and contained all correct documentation. Criminal Records Bureau Checks, (CRB’s), obtained before recruitment, were seen to be on place for three members of staff recruited since the last inspection. A record of a training session on care planning and Waterlow risk assessments had been held on 30/03/06. On the day of the inspection the deputy manager was undertaking training on dementia with staff. Two new members of staff had been recruited from Bulgaria. One of these was spoken with had limited English language skills. A relative spoken to said that although their verbal communication with residents was limited at present, they would not like to complain as these carers had particularly lovely manner with residents. The deputy manager advised that language was an issue, and that these staff were awaiting places on English for speakers of other languages (ESOL) courses. Training certificates were maintained on individual staff files. Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,38 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home is generally well managed, however requirements in respect of medication and health and safety indicate that there needs to be tighter monitoring in some areas to ensure that risks to residents are minimised. 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 home had provided an action plan following the previous inspection, noting that all requirements were accepted and would be or had been addressed. This Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 23 was found to be the case, although a number of new requirements were made, mainly in respect of the upkeep of the environment. The home’s Certificate of Registration and public liability insurance certificate were correctly displayed. The Service User’s Guide contained the results of a quality assurance exercise undertaken with residents and relatives in December 2004. It included comments and an analysis of responses to a questionnaire which covered care, staffing, environment and quality of life issues. The manager advised that a recent exercise had been conducted but that this hadn’t been written up yet. One of the residents spoken to confirmed that they had received a questionnaire from the home. A resident spoken with said that there had not been a resident’s meeting for some time. Another, talking about this said, “ Not many are interested, I feel it’s hardly worth holding. I don’t feel many would want to be bothered.” Notes of the last staff meeting were seen, this occurred in March 2006. The deputy manager advised that the manager did keep monies for some residents, but that they did not have access to these. This will be fully inspected at the next inspection; this standard has been found to be met at the previous two inspections. Supervision records seen showed that this had occurred in March and May 2006. The deputy manager advised that this is held at 8 weekly intervals. Staff appraisals had also been held. The home had a critical control point hazard analysis in place for food production. Records of fridge freezer and meat temperatures were seen to be maintained. Fire extinguishers were checked and had been services recently. The fire logbook showed that the system had been tested quarterly, and included details of current fire training. Residents sitting outside in wheel chairs all had foot plates correctly in place. A number of concerns relating to health and safety were found in the environment, and are detailed under this section. Westhorpe Hall Residential Home DS0000024524.V304451.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 X 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X 3 3 3 X 2 Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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. 2. 3. 4. 5. 6. Standard OP9 OP12 OP19 OP19 OP19 OP25 Regulation 13(4) 16(2)(n) 23(2)(d) 13(4) 23(2)(d) 13(4) (a)(c) 13(4) 23(2)(o) Requirement MARs sheets must be complete, and any omissions explored. The activities programme must be developed. Decorations in corridors must be maintained to a good standard. The side patio area must be made up to a good standard. The carpet in the dining room must be cleaned to a good standard or replaced. The home must evidence that water temperatures at the boiler are monitored and maintained above 60 degrees Celsius. To reduce the risk of cross infection, towels must not be kept in communal bathrooms. The grounds in the immediate vicinity of the house must be kept free of rubbish and trip hazards. Striped tape marking hazards on the floor must not in itself represent a trip hazard. Timescale for action 18/07/06 31/08/06 30/10/06 31/08/06 30/09/06 31/08/06 7. 8. OP26 OP38 18/07/06 18/08/06 9. OP38 13(4) 18/08/06 Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP7 OP12 Good Practice Recommendations The review of care plans to include goals for residents care and pressure area risk assessments should be completed for all. Daily care notes should also include reference to residents Social and emotional well-being and their participation in meaningful activities, to ensure that this aspect of the residents life can be monitored at review and appropriately responded to. The daily menu should be available in written form for residents to access at their leisure. The recommendations from the Occupational Therapist report should all be carried out. The home should continue to develop the percentage of staff with NVQ 2. Meetings for residents and staff should occur regularly. The Responsible Persons should provide a business and financial plan. 3. 4. 5. 6. 7. OP15 OP20 OP28 OP32 OP34 Westhorpe Hall Residential Home DS0000024524.V304451.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Westhorpe Hall Residential Home DS0000024524.V304451.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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