Inspection on 01/06/07 for Westlea

This inspection was carried out on 1st June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westlea 20/10/08

Westlea 20/04/06

Westlea 06/12/05

Westlea 17/02/05

Westlea 19/10/04

Westlea 18/03/04

Westlea 17/11/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Westlea 121 High Street Leagrave Luton Bedfordshire LU4 9JZ Lead Inspector Mr Ian Dunthorne Unannounced Inspection 1st June 2007 14:15 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 Westlea DS0000033142.V338342.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. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westlea Address 121 High Street Leagrave Luton Bedfordshire LU4 9JZ 01582 574587 01582 847232 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) Luton Borough Council Vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Westlea was a large Luton Borough Council home that accommodated 33 residents, 6 of these beds provided respite care on a short-term basis. The registration certificate was changed to reflect the present category of residents in the home since the last inspection, following the home’s application to change the nature of the care provision it offered and the subsequent assessment by the Commission for Social Care Inspection (CSCI) to ensure the home could comply with this provision of care. This change was as a result of two nearby local authority home closures and consequently the transfer of some of those residents to this home. The manager of the service at that time took the opportunity to retire from the position and the manager from one of the local authority homes that closed transferred to adopt the vacant post at this home. At the time of the inspection the new manager of this home was in the process of her application to register as manager with CSCI. The home was located on the main high street in Leagrave and provided access to local amenities. The main advantage of the location was the vicinity of the Leagrave medical centre. The accommodation included single occupancy bedrooms. Two large lounges/dining areas, bathrooms and toilets were strategically placed within the home. The home had separate smoking room and visiting areas, a hairdressing room and a shaft lift which provided access to both floors. The home provided parking facilities for several cars and had maintained gardens surrounding the building, which were accessible by the residents and a conservatory to the rear of the home. The home provided a purpose built and domestic in style environment. Information provided regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in January 2007, both stated that the weekly fee ranged from £70 to £529, exact fees were published in individual service users contracts. Any additional fees not included were also specified and that they would incur an additional charge. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six hours during the afternoon & evening and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from residents, relatives and visitors obtained from postal survey questionnaires. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the manager, discussion with residents and observation of the routines of the home. No relatives were available during this inspection to speak with. The method of inspection was to track the lives of several residents. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and relatives and reviewing their records. Postal surveys had been sent to the home for the residents to complete prior to this inspection, however they had not been issued by the home and the home was unable to provide an explanation why this was. Therefore this information could not be provided as part of this inspection report. As described in the section above ‘Brief Description of Service’, the home was going through some substantial changes and subsequently a transitional process, demonstrated in many areas of work that were in progress at the time of the inspection within the home. This was as a result of a new manager, redevelopment of the service it offered and some of the building itself, staff integrating into the home and its existing staff team from other homes as a result of redeployment following two nearby local authority home closures. And in addition new residents who had transferred from the two nearby local authority homes, which had closed, were still settling, adjusting and integrating into their new environment. What the service does well: The home was able to help residents make a choice about whether the home was right for them, by providing them with up to date information in a suitable format for them and assessing the residents needs with them. The home was able to demonstrate that they treated the residents with dignity and respect. One resident commented during the inspection “the staff are very kind to me, they talk to me nicely, they understand me and are patient with me”. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 6 The meals provided by the home for the residents were of a good standard. One service user said “the food is good and we get a choice, I don’t like fish so they give something else that I ask for”. The home had a positive approach to complaints and made sure people knew how to complain. One resident said, “If I’m not happy I can talk to the manager”. The home was kept clean and pleasant. The manager had the qualifications and experience to run the home. What has improved since the last inspection? What they could do better: Some of the things that the home could do better include: • • Ensuring that resident’s wishes are considered & documented in the event of dying and death. The manager acknowledged that the home’s provision of activities both inside and outside of the home, required further development to meet the needs of people who used the service. Providing suitable activities, that people who live at the home choose, which they will enjoy and benefit from. Making sure that all residents are consulted and agree to information about how their care should be delivered and provided by staff. Ensuring that residents’ bedrooms maintain their health & safety. Reducing the risk of residents developing pressure sores by making sure the risk is assessed and then following any actions necessary. • • • • Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 7 • • • • • Ensuring that medication is properly and safely looked after and given to residents and that clear, accurate records are kept. Informing CSCI of any concerns or reportable incidents that may have placed residents at risk of harm or abuse. Ensuring that the home is safe for residents and staff to live and work in. Providing training for staff, which would help them understand and meet some of the specialist needs of the residents. Asking for the views of others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out. 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. Westlea DS0000033142.V338342.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 Westlea DS0000033142.V338342.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): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided up to date & reviewed information about its facilities and services and in a suitable format; which were supported by needs assessments to enable prospective residents to make an informed decision about admission to the home. EVIDENCE: The home’s statement of purpose and service user guide had been reviewed and they were available and displayed in a suitable format for some of the residents intended and provided information to enable prospective residents to make an informed choice about whether to stay. Both contained the necessary information required. Residents who were spoken with as part of the inspection supported that evidence. The homes last inspection report was displayed and available within the home. Further information was provided in the form of the minutes of the last residents meeting, displayed on the reception notice board in a suitable user-friendly large print format. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 10 Evidence examined confirmed that the residents whose lives were tracked had written contracts with the home, provided with a statement of terms & conditions at the point of moving into the home; this included the fee details. The contracts examined had been signed by the resident or their representative, which authenticated and confirmed their agreement with the terms and conditions. The manager demonstrated that she was in the process of reviewing and re-issuing contracts as found necessary. There was evidence that the home had undertaken an assessment of the residents needs on admission and then regularly reviewed this information and updated it when those needs changed; the needs assessment helped them form the basis of their care planning process. They had also been provided with a summary assessment from the referring care management service, which they had used to form part of the information that contributed to their own needs assessment. Those records examined of the residents whose lives were tracked, had been signed the residents, which confirmed they had been consulted and their agreement sought. The home did not admit service users for intermediate care. Westlea DS0000033142.V338342.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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s care plan system and supporting documentation required further development and consolidation to prevent confusion and therefore subsequently improve how residents needs are understood and communicated to be met. Residents’ care plans were satisfactory to meet their daily needs, although further development was needed to ensure residents or their representatives were consulted to ensure their involvement and agreement with their care plans, including any changes made to them when reviewed. EVIDENCE: A sample of the residents’ care plans and supporting documentation, including risk assessments were reviewed and found to contain satisfactory information to help meet their daily needs. However, there was no evidence for those residents whose lives were case tracked, that they or their representatives had been consulted when the plans were drawn up. There was evidence that the residents care plans were being reviewed, however evidence of any clear evaluations and changes necessary were absent. The presentation and format Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 12 of some care plans, including the format for reviewing them was of limited quality. This was demonstrated by repetitive care plans; one resident had four care plans for the same need, diabetes, which could cause potential confusion for carers when referring to this document. Some supporting information had not been consolidated effectively yet into one re-developed system at the home, following the transfer and relocation of residents to the home from the two local authority home closures, whose information was presented in differing formats. Evidence of care plan reviews was provided by carers recording the date when reviewed down the side of the care plan page in some cases, each month, resulting in unclear, poor presentation, with seemingly no changes required as a result of the reviews, of those who were examined. There was no evidence that the resident or their representative had been involved in the reviews, or consulted about any changes made to the residents care plan if any were made. Not all residents care plan documentation was accompanied by an identification photograph of the resident. Risk assessments with particular attention to the prevention of falls had been completed and reviewed at suitable intervals. The health care needs of the residents were generally met by the home satisfactorily. Further development was needed to ensure tissue viability assessments were completed when necessary for each resident. Residents weight had been monitored which supported other records completed by the home. Information, guidance, documentation and monitoring records were evident for some residents with specific health care needs such as diabetes for example. Evidence available supported the fact that residents were enabled by the home to access a variety of health care services, to meet their assessed needs, evidenced by records of a dieticians and occupational therapists visits. No residents were self-medicating at the time of this inspection. Samples of medication records, storage and procedures were checked, of those residents whose lives were being tracked as part of this inspection. All staff administering medication had recently received training. Medication was observed in part being delivered to residents during teatime. Further development was needed in the following areas, to ensure that staff always record on the medication administration record (mar) when medication has been administered and inversely should not record as given on the mar sheet when medication has not been administered, there was evidence of this on three separate occasions over a one week period. In addition any changes made to the mar sheets prescribed medication details or instructions by the home, must be supported by the written agreement of the prescribing practitioner before doing so and any handwritten entries should be dated and signed as such, there was evidence that this was not the case on one occasion of those records sampled. The evidence from speaking with some residents was that they were treated with respect and their rights to privacy were upheld and this was consistent Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 13 with observations made during the inspection. Residents had access to a phone, which was portable, enabling them to use it in private if they wished One resident commented “they treat me like an adult here, the staff are very helpful”. Staff were observed knocking on residents bedroom doors, bathrooms and toilets before they entered. The home had a death and dying policy, however there was evidence that residents’ wishes in the event of terminal illness or death was not considered and subsequently not recorded in their care plan. This was made a requirement following the last inspection. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. The quality, variety and amount of suitable activities provided by the home were unsatisfactory and residents were not provided with suitable and sufficient opportunity to pursue interests or activities, either independently or with support. This prevented residents from exercising their choice, participating and benefiting from enjoyable, stimulating leisure activities to meet their interests and needs. EVIDENCE: No activities provided by the home were observed during this inspection. Generally activities provided by the home were limited. Staff spoken to said there was no time to provide activities and any activities there were, were limited to within the home and did not include any planned trips or outings. There was no evidence that any staff had attended any specialist training to support them to deliver suitable activities and no specific staff member was allocated the responsibility of an ‘Activities Organiser’. This was a requirement at the last inspection and the manager acknowledged that further improvement was required. Residents spoken with reflected this view and Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 15 indicated that they would enjoy more activities and things to do within the home and planned trips and outings outside of the home. There was evidence that the home observed people who lived at the home religious needs satisfactorily. Representatives and members of different faiths visited the home regularly. Evidence suggested that resident’s were able to maintain regular contact with their relatives and friends without restrictions and were supported to maintain contact if they wished, by the home. Residents spoken with said their relatives and visitors were able to visit them at any time and they were able to receive visitors in private. Some residents were supported to maintain contact with community links, demonstrated by one resident with an ‘Outreach’ representative. There was evidence that residents were encouraged to bring personal possessions with them into the home. Resident’s bedrooms were individualised with their personal possessions, which those spoken with said they were able to bring in with them. The home was able to demonstrate that they supported resident’s to maintain as much choice and control over their lives as possible in most areas, including supporting those who were able to continue to handle their own money for as long as they wished to and had the capacity to do so. Meetings facilitated by the home for the residents were held on a regular basis. There was evidence that an advocacy service visited the home on an ‘as required’ basis. Observations were made over the tea time period during this inspection and residents appeared unhurried by staff during this period. Resident’s were observed being offered a choice of meals and beverages and those with dietary or cultural needs were being accommodated for, including diabetics. Evidence of the home addressing individual nutritional needs, was also evident within residents care plans. Menus examined generally offered choice and a nutritious and wholesome diet to the resident’s, with a balanced and varied selection of foods. Menus were displayed with the choices on notice boards within the home. The home offered suitable food portions that were well presented. Residents spoken with said they enjoyed the meals at the home and one said, “the food is great and if you don’t like to choice they’ll give you something else that you do like”. However residents had not been consulted about the set menu choice, although they could deviate from it; which the manager acknowledged was an area in which they would be seeking improvement. Westlea DS0000033142.V338342.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 adequate. This judgement has been made using available evidence including a visit to this service. The home had satisfactory complaints and adult protection procedures in place, which ensured that complaints were listened to and residents were safeguarded from abuse. However further development of the implementation of their procedures were required, to ensure that CSCI were always notified of any concerns relating to the protection of the residents to ensure their safety could be adequately maintained. EVIDENCE: The home had received no formal complaints since the last inspection. A record was kept of all concerns & complaints previously made. The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. Residents spoken with were aware how to complain and who to and they said they felt comfortable and confident to complain. The homes complaints procedure information available to residents, relatives and visitors on the day of the inspection, was available and displayed in the home’s reception foyer. Information of how to complain was also included in the information provided to resident’s and or their relatives / representatives on the residents admission into the home. One resident commented during the inspection “there are residents meetings every month, so we can voice our opinion and if we’re not happy we can talk to them there”. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 17 The home had satisfactory procedures in place to safeguard residents from abuse. The majority of care staff had received POVA training, however several staff required refresher training and some staff did not appear to have fully grasped the concept of the training. The manager acknowledged this and had already requested additional training which she provided evidence of. Most care staff spoken to knew what to do in the event of witnessing an alleged case of abuse occurring. Since the last inspection there had been one notifiable incident in accordance with the POVA policy and guidance, which however was not reported to CSCI at the time. Evidence examined, supported a process that had been followed to safeguard and protect residents. The homes policies and practices regarding resident’s money and financial affairs were generally satisfactory and protected residents from abuse. Money held by the home for two resident’s whose lives were tracked, was checked and balanced with the records held. The money was stored safely and individually for each resident. Westlea DS0000033142.V338342.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, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. However there were some identified risks, which need to be addressed, to minimize potential risk to residents and safeguard their health and physical well being. EVIDENCE: The grounds of the home were tidy, well maintained and allowed access to residents. There was clear evidence during the inspection that a rolling program of maintenance and improvement had begun at the home, demonstrated by general works to the fabric of the building, including refurbishment throughout various areas of the home, a new lift and replacement fitted laminate flooring. However some areas of the home still required attention such as for example some tiles in a bathroom upstairs had become loose and the front entrance Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 19 and external emergency exits appeared very tired. The manager was able to provide evidence that these areas of concern were to be addressed in the home’s schedule of maintenance and refurbishment works in the near future. Some walled areas of the home appeared bare and not homely, it was explained however that pictures were in the process of being put up by the maintenance person who on holiday at that time. Communal space was available within the home, which included an area residents could meet visitors in private and outdoor space provided for residents accessible, which included a new conservatory and outdoor seating. Both areas were safe for residents to make the best use of them. A dedicated smoking room for residents was available. Various communal furniture throughout the home had been replaced, as part of the ongoing refurbishment program to improve the quality of the homely environment. Specialist equipment was provided and observed within the home to help maximise service users independence. This included different types of hoists, grab rails and assisted toilets and baths. A new specialist shower room downstairs had been fitted and was operational since the last inspection. Staff spoken with found it poorly designed to meet the residents’ needs and to protect their own as well as the resident’s safety due to the limited size, position and access to it within the bathroom. Observation of this during the inspection confirmed the described impracticalities and risk presented by its use. Several bedrooms were inspected during the inspection and were all found to suit the needs of the residents. The décor was suitable and some re-decoration in places was relatively recent. A program of regular redecoration of resident’s bedrooms was evident. Residents were given the opportunity to personalise their room with various furnishings, which the home had supported them to do. A requirement had been made at the last inspection to safeguard residents from tripping over lengthy call bell system cords in their bedrooms. There was evidence that the home had taken some action to rectify this by wrapping the cord around the overhead bed light. However, there were still clear concerns as the excess cord wire was now hanging precariously above residents heads whilst they were in bed and could potentially if pulled dislodge the light or cause entanglement of the resident due to the length of the wire. Therefore the home had failed to adequately resolve this with a safe and suitable solution. The home appeared suitably clean and free from offensive odours, more suitable flooring had been fitted, which made the area appear clean & pleasant. Several residents commented how clean their rooms were kept. Training records identified some staff that had undertaken infection control training. However further development was required in some areas to promote effective infection control practices. For example the homes laundry Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 20 procedures did not comply with recommended infection control guidance for care homes, mainly due to the limited environment available that required upgrading to eliminate the present hazards. Westlea DS0000033142.V338342.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. Mandatory training provided for staff was generally satisfactory. However, the level of specialist training provided for staff to meet the needs of the residents was limited, which could compromise the health and wellbeing of those residents. EVIDENCE: The home provided sufficient numbers of staff to meet the ratio of residents in the home. On the day of the inspection five care staff were available from lunch time to meet the needs of twenty-nine residents, this number included the duty senior, during the evening three of those staff were provided by an agency. The home had recently begun the integration of re-deployed staff from two local authority homes as a result of their planned closures, which had previously prevented them from recruiting their own staff as the posts were ‘frozen’ in anticipation of the re-deployed staff. However staff ratio’s had not yet increased as a result and there were still vacant care hours which the manager explained amounted to approximately one hundred hours. The manager said the vacant hours were about to be externally advertised following internal advertisement due, to the previous redeployment status and job freeze, as five, part time, twenty hour positions, which if successful it was anticipated would increase the home’s staff ratio and reduce their agency usage. Several residents and staff expressed concern that there weren’t always Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 22 sufficient numbers of staff on duty to work effectively and that they were very challenged and ‘stretched’ to meet the needs of the residents and complete all their tasks. Comments to this effect were made several times during the inspection. The percentage of staff qualified at nvq (national vocational qualification) level 2 or 3, fell below the minimum required level of 50 . The manager explained that several staff would be commencing this qualification on the next planned cohort on 16th June, in an effort to improve their compliance and the number of qualified staff required. Staff records examined indicated that the homes recruitment procedures were generally satisfactory. Staff that were spoken with supported this evidence. However applicants for employment did not always provide details of their full employment history and there was evidence that the home failed to pursue this before subsequently offering them employment. Staffs records inspected, showed evidence of individual training but no specific development plans. Staff members spoken with reported various training which they attended, including some recently. Not all staff had received up to date POVA training see ‘Complaints & Protection’ section of this report. Many staff had not received necessary specialist training to meet the needs of the residents, as the home had not provided it. There was evidence that the home provided staff with the necessary mandatory training, which included a program of fire, health & safety, moving & handling and first aid, which was supported ordinarily by regular refresher training, which the manager was in the process of submitting several staff nominations which were evidenced, as they were not all up to date. One senior staff member had recently been allocated the task of overseeing staff training, which appeared to be making positive improvement steps. The home failed to provide a satisfactory level of specialist training for staff regarding continence, diabetes, sensory impairments and food hygiene necessary to meet the needs of many of the residents. Westlea DS0000033142.V338342.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, 33, 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’ views were sought from time to time, but there was limited evidence that their views had much effect in changing how the home was run, & some aspects of the homes health & safety and safe working practice procedures needed further development to ensure residents & staff would be protected from the risk of harm. EVIDENCE: The manager Trish Pugh was present during the first part of this inspection. The manager said that she had NVQ level 4 and 5 in management and she had completed her Registered Managers Award (RMA). Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 24 The home did not have a fully effective quality assurance system in place. The manager said that surveys were conducted annually for residents. However, the statistics were not translated to anything meaningful and there was no annual development plan from the results. Outcomes for residents were not identified, although the manager said that any items to be addressed would have been completed. However she was unable to provide evidence of this as she explained she was not the manager of this home at the time, when the process was last completed and that the review cycle was next planned for September this year. There was no evidence that views of others such as GP’s, nurses and chiropodists had been sought. However, the manager explained that this area was currently undergoing further development. Resident’s financial records and secure safekeeping of money and valuables, were being maintained satisfactorily on behalf of the residents by the home when necessary. The residents financial interests were safeguarded by the home, this protected the interests of the residents. However a witness signature had not been obtained for all financial transactions carried out on behalf of residents, whose money they looked after, although there was evidence that the balance was checked and signed by a witness on a weekly basis but not for each individual transaction. Evidence examined and staff spoken to demonstrated that staff received supervision and appraisals, although it wasn’t always regular and team meetings were held at intervals for both day and night staff. Some records it was noted had a number of entries made by staff who had signed to authenticate care records using their first name only, or variations of their initials only, as opposed to their full names for clear identification purposes. In addition several daily care records and care plans of residents examined, demonstrated that a generic system of abbreviations were used by care staff when recording. Some aspects of the homes health & safety safe working practices, required some improvements to protect residents from potential risk or harm. See ‘Environment’ section of this report and in conjunction with the associated maintenance program refurbishment works. Such as for example, there was some evidence observed within the home’s small kitchenette fridges and other areas of the home that safe food hygiene practices were not being consistently maintained by staff and in one of these areas there were no hand washing facilities available. The radiator in one toilet was exceptionally hot, although the thermostatic radiator valve fitted indicated that it had been switched off. A specialist bath mat for supporting resident’s comfort whilst in the bath was observed to require thoroughly cleaning, in the same bathroom a wooden chair was in place, neither of which promoted effective infection control procedures. Various records were examined associated with health & safety and safe working practises. Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 25 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 2 X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 2 2 Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 26 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. Standard OP7 Regulation Requirement Timescale for action 31/08/07 15 (2) (c) Where possible consultation must be sought from residents about the intended care to be implemented by the home. The care plan should be signed by the resident or their representative on their behalf, to acknowledge the involvement, agreement and consultation with the resident and the care plan should be recorded in a style accessible to the resident. 13 (4) (c) Resident’s tissues viability must be assessed by a person trained to do so and any necessary intervention recorded in their plan of care to ensure their health and welfare and prevent pressure sore development. Staff must adhere to the homes’ policies and procedures for the receipt, recording, storage, handling, administration and disposal of medicines. A record must be kept for all residents detailing their wishes DS0000033142.V338342.R01.S.doc 2. OP8 31/08/07 3. OP9 13 (2) 31/07/07 4. OP11 12 (1) (a), 12 31/08/07 Westlea Version 5.2 Page 27 (2) in the event of their death. Previous timescales: 30/01/06 & 30/07/06 not met. All residents must be given the opportunity to have satisfactory stimulation throughout the day. Previous timescales: 30/01/06 30/06/06 not met. 31/08/07 5. OP12 13 (4) (b) 6. OP18 37 (1) (e) & (g) Any concerns, including 31/07/07 reportable notifications regarding abuse, neglect and the safety and protection of residents being compromised must be reported to CSCI. Safe and suitable bathing facilities must be provided to meet the needs of the service users. Arrangements must be made to ensure the safety of the residents in their bedrooms with regards to trailing wires for call point systems. Previous timescale 30/06/06 not met. The home must ensure that the spread of infection is controlled & minimized in accordance with relevant legislation and published professional guidance, with regard to laundering systems & procedures. Staff must receive training appropriate to the work they are to perform, including specialist training to meet the needs of the residents. An effective quality assurance system must be introduced as specified by this standard. DS0000033142.V338342.R01.S.doc 7. OP22 23 (2) (j) & (n) 31/08/07 8. OP24 12(1) 31/07/07 9. OP26 13 (3) 31/08/07 10. OP30 18 (1) (c) (i) 31/08/07 11. OP33 24 (1) (a) (b) 31/08/07 Westlea Version 5.2 Page 28 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 OP15 OP28 Good Practice Recommendations Residents should be consulted and included in devising the home’s menu choices and their arrangements. Arrangements should be made to ensure a minimum of 50 of the care staff receive their NVQ level 2 in care qualification. The home should ensure that applicants for employment provide details of their full employment history. Staff should be supported by ensuring they receive regular supervision & appraisal. Care staff should ensure that they sign documented care records with their full name on each entry and generic use of abbreviations should be avoided, as this can prevent residents understanding information held about them. 3. 4. 5. OP29 OP36 OP37 Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Westlea DS0000033142.V338342.R01.S.doc Version 5.2 Page 30 - 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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