CARE HOMES FOR OLDER PEOPLE
Westlands Station Road Wem Shrewsbury Shropshire SY4 5BL Lead Inspector
Pat Scott Unannounced Inspection 10th February 2006 09:45 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 Westlands DS0000020706.V268714.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 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. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Westlands Address Station Road Wem Shrewsbury Shropshire SY4 5BL 01939 232784 01939 235295 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) Coverage Care Shropshire Limited Miss Jane Louise Capewell Care Home 40 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (16) of places Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The Home is registered to accommodate a maximum of 40 Older People to include a maximum of 24 people with Dementia. 20th September 2005 Date of last inspection Brief Description of the Service: Westlands is a residential Care Home registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of forty people over the age of 65, within this number a maximum of 24 people who have dementia may be cared for. The home does not provide Nursing care. The home is conveniently located close to the town centre in Wem, Shropshire. Accommodation is situated on the ground floor of the home and all service users are provided with a single bedroom. The rooms are attractively decorated and personalised. None of the rooms have an en-suite facility. Communal areas are bright well furnished and the décor of a high standard. The home is owned by Coverage Care (Shropshire) Ltd and the Registered Manager is Ms Jane Capewell Westlands DS0000020706.V268714.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 on the 10th February commencing at 09.45hrs for the duration of the morning. The National Minimum Standards for Care Homes for Older People focus on achievable outcomes for service users – that is the impact on the individual of the facilities and services of the home. Evidence was looked for that the standards were being met and a good quality of life enjoyed by service users through: • Discussions with service users, families and friends, staff and managers. • Observation of daily life in the home • Scrutiny of written records. The statement of purpose was used to assess how far the home’s claims to be able to meet service user requirements and expectations were being fulfilled. Reports regarding an overview of the conduct of the home are sent to CSCI on a monthly basis by the Head of Operations for Coverage Care. These, as well as the risk assessment from the last inspection were taken into account to determine the core standards focused on and depth of inspection. The Commission does not currently have any concerns regarding this home. What the service does well: What has improved since the last inspection?
Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 6 There were no requirements made at 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. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 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 Westlands DS0000020706.V268714.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. EVIDENCE: Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 9 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): 9 The medication at this home is very well managed promoting good health. EVIDENCE: Medicines are kept safely with full records of their receipt, administration and disposal. Reviews of medication are conducted by the GP on a regular basis. Wherever possible and depending on their capabilities, service users are enabled to take responsibility for their own medicines. One service user does this who had signed a self-medication agreement. The only homely remedy the home uses is Paracetamol, authorisation for which has been signed by the GP to administer within stated guidelines. Service users stated that they receive their medication on time. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed at this inspection. EVIDENCE: Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 11 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 home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff are provided with induction and on-going training regarding adult protection. This provides staff with the relevant knowledge to safeguard service users from many types of abuse. EVIDENCE: Recent complaints made to the home and the CSCI from the same complainant have been dealt with through the homes complaint process. An on-going adult protection issue is also dealt with through the correct channels with full liaison with social services and the CSCI. Discussions take place about adult protection in the 2 monthly staff supervision sessions. Examples of this process were recorded on staff files. Service users seen had a good rapport with the staff on duty and looked at ease in their presence. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 12 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): 26 The home has systems and training in place to ensure that it is clean, pleasant and hygienic. EVIDENCE: Coverage Care invests in staff training for infection control once a year. A record is kept of all training attended from induction to regular updates. All levels of staff participate in such training so that the whole team work together to create a safe, hygienic place to live. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed at this inspection EVIDENCE: Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 14 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): 33,35 Service users views are regularly sought and they perceive them as having an effect in changing how the home is run Service users personal monies are well managed so that their financial interests are safeguarded. EVIDENCE: The system for keeping and recording service users’ personal allowances was examined. Accurate records are kept with the money of one reconciling with the balance. Coverage care conduct a yearly satisfaction survey that has taken place. The outcome of this is included in the service user guide and sent to the CSCI.
Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 15 Service users may attend a monthly meeting in the home where they can air their views. Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westlands DS0000020706.V268714.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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