Inspection on 29/07/05 for Westlands House

This inspection was carried out on 29th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westlands House 26/01/09

Westlands House 05/09/06

Westlands House 29/11/05

Westlands House 16/12/04

Westlands House 25/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Westlands House Headmoor Lane Alton Hampshire GU34 3EP Lead Inspector Marilyn Lewis Unannounced 29/07/05 09:30 a.m. 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 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 House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westlands House Address Headmoor Lane Alton Hampshire GU34 3EP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01420 588412 Ms Lesley Tagima Ms Lesley Tagima CRH 17 Category(ies) of DE(E) Dementia over 65 OP Old age registration, with number of places Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No more than 2 service users in DE(E) at one time Date of last inspection 16/12/04 Brief Description of the Service: Westlands House is a former private residence that has been converted into a care home for older people and those over the age of sixty-five years with dementia. Seventeen residents are accommodated in fifteen single rooms and one shared room. Thirteen of the single rooms and the double room have ensuite facilities. The home is situated in large gardens, in a pleasant rural location on the outskirts of Alton, Hampshire. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours on the 29th July 2005. The inspector toured the home and had the opportunity to meet eight residents, a senior carer, activities co-ordinator, administrator, cook and registered manager. Care plans were sampled for three residents and records were seen for two members of staff, medication, fire safety and drills. Service users at the home prefer to be known as residents, as this has been respected. What the service does well: Major building work is currently underway at the home and every effort is being made to minimise the disruption and upset for residents. No one is admitted without a full care needs assessment and the home provides clear information on life at the home for prospective residents who are able to visit the home to ensure their needs will be met. Good care plans give staff the information required to fully support residents throughout their stay at the home. Staff follow clear procedures when dealing with medicines, minimising the risk of error and protecting residents safety. Residents are able to exercise control over their lives and can choose to participate in a varied and interesting programme of activities. Residents are offered a choice of balanced, appetising meals, served in a friendly, relaxed atmosphere. Residents know that their complaints will be taken seriously and acted upon and are protected by the staffs’ awareness of abuse issues and their knowledge of the procedures to be followed should abuse be suspected. The home provides a safe, clean environment, with comfortable communal rooms, personalised bedrooms and sufficient, suitable bathroom and toilet facilities. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 6 Residents are protected by the homes’ robust recruitment procedures and their needs are met by the number and skill mix of staff employed at the home. Residents and staff benefit from strong leadership, the open approach to management, good financial procedures and quality monitoring systems of the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 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 standard(s) 1, 2, 3, 5 and 6 No one is admitted to Westlands House without a full care needs assessment and prospective residents are able to visit and are provided with clear information on life at the home to assist them in making a decision on taking up residency. EVIDENCE: The home has a statement of purpose and service user guide in place, combined in one document. The document provides clear information on the services and facilities provided at the home and gives details of the qualifications and experience of the registered manager and care staff. The document is clearly written and in a suitable format for prospective residents and their relatives. The home is currently undergoing major refurbishment that will increase the number of residents accommodated and the statement of purpose and service user guide are being reviewed to include the additional information required. When the new documents are produced they will be in a more defined format, separating the statement of purpose and service user guide. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 9 Each resident is provided with a clear written contract detailing the terms and conditions for residency at the home. The contract states the services included in the fees and informs the resident of services available at an additional expense such as hairdressing and chiropody. A full care needs assessment is undertaken for each prospective resident prior to being accepted for admission to the home. The assessment is undertaken by the registered manager or the deputy manager, at the prospective residents’ home or place of residence. All aspects of care needs are included in the assessment including mobility, history of falls, social needs, cultural needs and medication. The registered manager said that prospective residents are invited to visit the home on a day basis to meet the residents and join with them for lunch. Relatives are also encouraged to participate in the assessment process. The registered manager said that the day visit gave staff an additional opportunity to assess the care needs of the prospective resident in the residential setting. At the time of the inspection visit, a prospective resident, who is due to occupy a room in the new build, was visiting for the day. The registered manager said that the prospective resident was anxious about leaving her home, and was visiting Westlands twice a week, prior to taking up residency, to minimise the upset when moving in on a permanent basis. Westlands House does not provide intermediate care and therefore this standard is not applicable to the home. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 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 standard(s) 7, 9, 10 and 11 Good care plans give staff the information they require to fully support the residents throughout their stay at the home. Residents are protected by staff following clear policies and procedures for dealing with medicines. EVIDENCE: The full care needs assessment forms the basis for the individual care plans. Care plans seen for three residents were good, providing the information required by staff to support the residents and ensure their needs are met. The plans contained details on all aspects of care and included a summary of the residents’ life history, medical history, daily routine and recreational interests. The records indicated that regular reviews took place and that the residents or their relatives were involved in the development and review of the care plans. The home has clear procedures for staff to follow when dealing with medicines. Only the registered manager, deputy manager and the senior carer, who have received training in dealing with medicines, administer the medication. Medication records seen had been completed appropriately and were up to date. At the time of the inspection no controlled medicines were in use and Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 11 there were no residents who self- administered their medication. Up to date information for medicines used at the home was available for staff and GPs frequently reviewed the medication prescribed to residents. It was evident during the inspection visit that residents were treated with respect. Staff were observed to knock on doors before entering a room and to speak to residents in a caring and friendly manner. Suitable locks are fitted to bedroom and bathroom doors and residents assessed as able to do so are provided with a key to their own room. During a tour of the home it was noticed that some bedroom doors had been locked by residents while they were in the communal rooms. One resident said that ‘the staff always treat us with respect and kindness’ The home has procedures in place that indicate a dying resident would be treated sensitively and with respect and residents’ wishes were noted in their care plans. The registered manager said that if at all possible, residents were able to stay at the home when dying. Advice and support was accessed through the GPs and district nurses. Relatives are able to stay and support their loved one as they wish, including overnight. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14 and 15 Residents are able to choose to participate in a varied programme of suitable activities, enjoy the company of visitors and are provided with a choice of balanced, appetising meals served in a relaxed and friendly atmosphere. EVIDENCE: The residents past hobbies and interests were documented in their care plans. The home employs an activities co-ordinator, who said that the activities programme has been developed to accommodate the wishes and interests of the residents. The activities available included bingo, puzzles, drawing, reading, walking in the surrounding countryside and to a nearby golf club where the residents enjoyed taking tea. Entertainers, including a band and a magician visit the home and theme events have been organised including sherry and wine tasting and Easter fancy dress day. Two local ministers visit the home frequently and services are held once a month for those who wish to attend. Visitors are welcome at the home at any time and the registered manager said that they were able to join residents for a meal if they gave prior notice. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 13 Residents’ preferences for participating in daily living activities were included in their care plans. The documents noted details such as the time they wished to get up, whether they would like a bath or shower and if they liked to spend time alone in their room. It was evident during the inspection that residents were able to exercise control over their lives, with some spending time quietly in their rooms, one doing jigsaw puzzles, one reading magazines and another knitting. During the visit the inspector spoke with the cook who said that the menus were developed taking into account the residents likes and dislikes for food items. The menus seen offered a variety of interesting meals. The main meal on offer for lunch that day was homemade steak and ale pie, mashed potatoes and peas followed by homemade treacle sponge and custard. Alternative meals were available for residents who did not wish the set meals. The meals served at lunch looked well presented and eight residents spoken to while the meal was in progress said that they were enjoying the food provided, with one commenting ‘ the meal was delicious’. Staff were seen to assist residents who required support in a friendly, unhurried manner. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 14 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 standard(s) 16 and 18 Residents know that their complaints will be taken seriously and acted upon and they are protected by the staffs’ knowledge of the procedures to be followed should abuse be suspected. EVIDENCE: The home has clear complaints procedures in place that states who will investigate the complaint and timescales for the process. The procedures are displayed in the main hallway of the home. The registered manager said that no complaints had been received at the home in the last twelve months. Three residents asked about the complaints procedure knew how to make a complaint but said that they had no need to do so. Procedures to be followed should abuse be suspected are readily available for staff, who all receive training on abuse issues during induction. Two staff members spoken to during the visit were aware of the procedures to follow and indicated that they would have no hesitation in acting if they had any concerns. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Although the home is undergoing major building work, residents are provided with a safe, clean environment, with comfortable communal rooms, personalised bedrooms and sufficient bathroom and toilet facilities. EVIDENCE: The home is currently undergoing major refurbishment to increase the number of residents to be accommodated to thirty-three, by the addition of a new wing to the side of the establishment. The refurbishment will provide another sixteen bedrooms, additional bathroom and toilet facilities, a large conservatory, separate dining room, new laundry room, and office. Almost all of the rooms in the home will be affected by the refurbishment, with many being made larger and all bedrooms being fitted with en-suite bathroom facilities. When the refurbishment is complete all residents will be accommodated in single rooms. The registered manager said that every effort was being made to minimise the disturbance for residents and one resident spoken to, whose room was very close to some of the building work taking place, said that there had been no Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 16 problem what so ever. When work has been completed on the new extension the current residents are to be transferred to the new rooms while work is carried out on the original property. Currently the home provides accommodation for seventeen residents in fifteen single bedrooms and one shared room situated on two floors. A stair lift allows access to both floors for those residents unable to use the stairs. Communal rooms look comfortable and homely. There are two lounges, one on each floor. Dining areas are provided in each lounge. The home also has an office, a hairdresser salon, a laundry and a bedroom that is used as a sleepover room when required. The hairdressing room and laundry are kept locked when staff are not present, to safeguard residents. The kitchen is domestic in style. Residents’ bedrooms seen, looked clean and were personalised with many items, such as photographs and ornaments. The registered manager said that residents were encouraged to choose the colours for the décor and furnishings of their rooms. Three residents spoken to while touring the home said that they liked their rooms and one commented on her pleasure at being able to bring her own furniture into the home. The home has sufficient suitable bathroom and toilet facilities and those seen during the inspection looked clean and tidy. Hoists are provided and ramps and grab rails are in place where required to ensure residents are able to maximise their independence. Many of the windows of Westlands House provide pleasant views over the large gardens and surrounding countryside. Seating is provided around the gardens and a patio area is being constructed to allow residents to walk outside more easily when the ground is wet. During a tour of the home it was noted that all areas of the home looked clean and well maintained. Staff receive training in infection control during induction and disposable gloves and aprons were readily available for staff. Visitors to the home have to ring a bell to gain entry and a record is kept of all people entering and leaving the property. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Residents’ needs are met by the number and skill mix of staff and they are protected by the homes’ robust recruitment procedures. EVIDENCE: The home employs the registered manager, deputy manager, senior carer, an activities co-ordinator and eight carers. Separate staff are employed for administration, catering, domestic and maintenance duties. The rotas seen indicated that two care staff members are on duty for each shift plus the registered manager and deputy manager are ‘hands on’ for the morning hours and are able to assist the care staff at any time of the day. Staffing levels are flexible and are changed to meet the care needs of the residents with the number of staff on duty increased if a resident requires high levels of care. Two staff members and three residents spoken to with regard to staffing levels said that there were enough staff on duty to meet the needs of the residents. The home has clear policies and procedures in place for the recruitment of staff. Records seen for two staff members, contained all the information required, including two written references and proof of identity. The registered manager said that agency staff were not employed at the home, with sickness and holidays covered by the staff team including the management. Criminal Records Bureau checks are completed for all staff prior to commencing employment at the home. The registered manager said that checks had also been completed for the hairdresser, manicurist, natural therapist, chiropodists and the builders. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 and 38 The residents and staff benefit from strong leadership, the open approach to management of the home and good, financial and quality monitoring systems. The lack of clear records for staff attendance at fire drills could residents’ safety at risk. EVIDENCE: The registered manager is also one of the registered providers for the home. She has been the manager of the home since 1996, holds the Registered Managers Award and is an NVQ assessor. The registered manager operates an ‘open door’ approach to management and two staff members spoken to said that she was very supportive. Three residents also commented on the support they received from the registered Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 19 manager and the deputy manager. One resident said that the registered manager was ‘very easy to talk to’. Staff meetings are held regularly. The meetings are recorded and the minutes are made available to all staff members. Meetings are also held for the residents. The registered manager said that more frequent meetings had been held while the building work was in progress to ensure residents were kept up to date with the work and any changes to the environment were discussed. Relatives had also been provided with information regarding the building work taking place at the home. The registered manager said that the views of the residents and their relatives were obtained through questionnaires as well as through one to one meetings. The information obtained was audited and action was taken to rectify any concerns. Comment cards received by the Commission from eleven residents and eleven relatives indicated that they were very satisfied with the care provided at the home. Examples of the comments made include ‘very satisfied with the wonderful and caring attention’, ‘Westlands is an excellent retirement home’ and ‘the genuine aim to care for the needs of the individual is outstanding’. The registered manager stated that no residents’ money is held at the home. Any expenses incurred by the residents, such as hairdressing, are billed monthly to the relatives. Receipts are kept for all transactions and a book keeper is employed to maintain the records. The deputy manager and the senior carer provide regular supervision for the care staff. The supervision sessions are arranged for a date and time suitable for both persons and the meetings are recorded. At the time of the inspection the kitchen looked clean and in good order with food stored appropriately and fridge and freezer temperatures monitored and recorded. Records seen indicated that up to date checks had been completed on the electrical system, boiler, specialist equipment including the hoists and stair lift. Records for staff training in fire safety were up to date but records for fire drill practices were unclear and did not provide evidence that all staff had received the fire drill practices even though staff members confirmed verbally that all had attended. It is a requirement of this inspection that records for fire drill practice clearly identify those staff members who attended. Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 3 x 2 Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38.2 Regulation 17(2) Schedule 4.14 Requirement The registered person must ensure records for fire drills clearly identify all members of staff who have attended fire drills. Timescale for action 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Westlands House H54 S12233 Westlands v227687 290705.doc Version 1.30 Page 23 - 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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