Inspection on 20/04/06 for Westlea

This inspection was carried out on 20th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westlea 20/10/08

Westlea 01/06/07

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 Andrea James Unannounced Inspection 20th April 2006 10:00 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.V288289.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. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 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 Mrs Theresa Freeley Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No of residents: 35 Gender: Male and female Categories: Older people (OP) Category: OP The category OP includes the ability to admit to the establishment people who require care because of their age but who have additional needs (such as dementia or physical disability) which can be met within the establishment’s resources and do not require a specialist service. Rehabilitation or breathing space services 19 beds may be used for rehabilitation or breathing space services, in conjunction with external nursing services. 9 beds may be used for Intermediate Care The service may admit up to 3 service users aged between 50 and 64 years in both Intermediate Care and Rehabilitation / Breathing Space beds. 06/12/05 5. 6. 7. Date of last inspection Brief Description of the Service: Westlea was a large Luton Borough Council home that accommodated 33 service users. Currently 6 of these beds are out commissioned as a result of alterations to the building and the installation of a new lift. The home normally provides 22 rehabilitation beds, 9 intermediate care beds, 2 permanent beds and 1 social care bed. It 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 home had various medical professionals visiting on a regular basis and provided a fast response to any health care emergency. The home provided a comfortable and homely atmosphere in a safe and domestic in style environment. The home’s main aim was to provide the respite and intermediate care and the majority of the beds were allocated to this purpose. The location of intermediate care beds was separate from permanent beds, as required by the standards. The home had the specialist equipment to offer all necessary care to its service users. The home works in close liaison with the Luton and Dunstable Hospital that used the beds to place service users. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 20th of April 2006. The Inspection process was enabled by the Registered manager, who was available for the duration of the inspection. The inspection process followed a case tracking methodology where samples of the service users were selected to inspect. These service users were spoken to and their files and documents inspected. The inspection report also reflects the views of staff nurses, care staff, relatives and the management team. The home was capped to only admit 20 service users due to recent investigations into the resource implications of staffing levels. This report is a key inspection for the service and therefore the majority of the standards were inspected. An audit trail was also carried out of falls of service users. One service user was used for this process. What the service does well: The home provides good standards of care to service users requiring rehabilitation after leaving hospital. The service works collaboratively with various other professionals namely social workers, nurses, rehabilitation team, and the CART team to ensure satisfactory care practice procedures are implemented within the 6-week time limit when the service users are expected to return to their homes. The home also provides good care to two permanent service users who have been in the home for a number of years. Relatives and service users spoke positively about the experience they received in the home and said they were made to feel welcome. Service users said the meals provided were of a high standard and staff treated them with dignity and respect. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? Since the last inspection various policies and procedures have been implemented to improve the care practice procedures for the service users. The home had new admission procedures, which required the involvement of various professionals. The assessment was completed at the hospital before service user could be admitted to the home. The criteria for admission was transparent and the home was able to choose whether or not to accept the service user based of the assessed needs of the service users and the resources available. The home had made improvements to their care plan procedures by ensuring all service users had a full care plan that identifies their needs. These were recorded by the social workers. The home had reviewed and developed their procedures for reporting and investigation abuse issues using the POVA (Protection of Vulnerable Adults) policy and ensuring that the Social services department are aware of all areas of concerns. The medication policies and procedures have been re-developed with the input of the Council and the PCT (Primary Care Trust) to ensure satisfactory safety measures are in place for service users. All staff received basic training and the home had started to explore the possibility of self- administration. The home had improved their recording procedures to ensure the wishes of service users in the event of their death was recorded but this needed further development. The home had installed a new lift, which provided better facilities for service users to access first floor of the building. The home had reduced the number of admissions to ensure the staffing levels are satisfactory for meeting the needs of the service users. The staff receive good standards of training that ensured they were able to meet the changing needs of the service users. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 7 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. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 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.V288289.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 and 6. “Quality outcome in this area was poor. The judgement was made using the available evidence collected and a site visit to the service”. Assessments were in place for most of the service users. The home had also ensured service users relatives were given the opportunity to visit the home in order to asses the facilities available as a result most admissions were satisfactory and the needs of the service users would be addressed adequately in helping to maximise their independence. The home was poor at ensuring service users are aware of all the admission procedures in relation to their care packages and as a result some service users felt unsure of the process of the care package. The home did not have copies of the service users contacts as these were made between social services and the Council and service users were entitled to receive their rehabilitation treatment free of cost through the National Health Service. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 10 EVIDENCE: The home had made improvements to their admission procedures, which ensured that service users received a full assessment of need prior to admission. This was done by professionals and it was clear that the home was rigid in ensuring the needs of the service users would be met through the assessment criteria. On the day of the inspection a service user was turned away when he arrived from the hospital without satisfactory paperwork or competed assessments. The assessments for the two permanent service users were not available and there was no evidence that their care package had been reviewed on a regular basis. Service users spoken to said they were not happy with the procedures of the admission as they were admitted to the home and given no information as to how their care would be implemented. They stated they did not blame the home but the various professional bodies that did not make their roles transparent. The home did not have copies of the service users contracts as these were made between social services and the Council and service users were entitled to receive their rehabilitation treatment free of cost through the National Health Service. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. “Quality outcome in this area was adequate. The judgement was made using the available evidence collected, speaking to service users, relatives and care staff on the day of the site visit which was carried out on the service”. Satisfactory processes were in place to ensure service users received good standards of care through their care planning, medication and health care procedures, which resulted in high standards of care for the service users receiving care. The home had improved on their procedures in ensuring service users wishes in the event of their death was recorded but the information provided was limited and did not suggest service users were able to make an informed choice. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 12 EVIDENCE: The home had made improvememts to their care plan procedures by ensuring all service users had a full care plan that identified their needs. These were written by the social workers and not the home and as a result it was difficult to identify how the home was meeting these needs. The only evidence of intervention was recorded in the daily notes and handover documentation. The manager explained that the care plans were used by all five teams that cared for the service users namely the home, the nurse team,,physio team, rehabilitation team and the CART team all their interventions were documented and kept in one file in the service users bedroom which was an improvement on the last system. The home manager explained that it would be difficult to write a care plan from just the homes perspective because the service users had so many packages of care. The home had two permananet service users and their care plans did not get reviewed monthly. The records showed that they were reviewed on the day before the inspection but no other record of reviews were documented for 5 months. The medication policies and procedures were also developed to ensure service users safety after a large investigation was undertaken in regards to adminstration of medicines in the home. The manager said all staff had an introduction training to medication but the team leaders who were responsible for admistering medication said they did not recieve any formal training but had the policy read to them and shadowed to ensure they were admistering medication safely. Team leaders said they were confident to adminsiter medication to the service users. The home was exploring the idea of ensuring service users who can should be enabled to adminster their own medication. Service users spoken to said they were treated with privacy and dignity. The home had some information in regards to meeting the wishes of service users in the event of their death but further information was required because the records only stated who to contact. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. “Quality outcome in this area was poor. The judgement was made using the available evidence collected on the day of the site visit and through communication with users of the service”. Service users received good standards of care in regards to the contact they had with their families, their ability to make choices over their lives and the meals they received. However opportunities for service users to engage in social activities was limited and as a result service users received very little stimulation. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 14 EVIDENCE: Service users and relatives spoke positively about the care they receievd in the home. They commented that the meals were of a good standard. One service user commented that he was gotten up two hours before breakfast and would prefer to have been left in bed until breakfast was ready. Several service users and relatives said their was not enough stimulation provided and as a result service users spent a lot of time in their rooms.Nurses also commented that service users spent too much time in their rooms and did not have sufficient stimulation which could delay their recovery. The manager had a record of all the times that service users were offered actvities but they refused and was concerned that she did not know how better to stimutate the service users. Care staff spoken to said they often encouraged service users to join in with activities but they often refused. Service users were encouraged to maintain contact with their families and on the day of the site visit several relatives were seen to visit the home. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 15 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 and 18. “Quality outcome in this area was good. The judgement was made using the available evidence collected from service users, relatives and information received on the day of the site visit”. Satisfactory processes were in place to ensure the service users and relatives could confidently report complaints or issues of abuse and expect satisfactory outcomes when necessary. EVIDENCE: The home had a major investigation in the past 6 months, which had a huge impact on the service, but the processes used for investigating the complaint were satisfactory and the complaint resulted in better care practices for service users. The home had received no other complaints since the last inspection. The home also had procedures in place to report and record POVA issues. Records showed that these were also resolved satisfactorily and where needed changes had been made to reflect better care practice procedures. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,24,25 and 26. “Quality outcome in this area was adequate. The judgement was made using information received from the service, a partial tour of the premises on the day of the site visit”. Service users were provided with individual bedrooms that ensured comfort to them while they received their treatments, as a result service users were comfortable. The home was clean and hygienic. Some areas in the home needed further development in regards to the decorating of some rooms and replacement of some furnishings. All call point systems had trailing wires that could cause compromise the safety of the service users. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 17 EVIDENCE: Since the last site visit the home had installed a new lift to the side of the building which resulted in better facilities for staff and service users. The home had also implemented a refurbishment programme where various areas of the homes environmental standards were identified to be improved in the financial year. A partial tour of the building was carried out on the inspection which showed that several bedrooms and communal areas were in need of redcorating and some furnishings were needing to be replaced. These along with some health and safety elements were reflected in the programme. Service users safety could be compromised in regards to the trailing of wires used for the call point sysytems in the service users bedrooms. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. “Quality outcome in this area was good. The judgement was made using the available evidence collected on the day of the site visit”. The service provided sufficient numbers of staff that were qualified, trained and competent in meeting the needs of the service users. The home had satisfactory recruitment procedures that were in line with employment laws. EVIDENCE: The home had satisfactory numbers of staff to meet the needs of the service users. The rotas showed that 6 care staff were available for 20 service users. This was complimented by nurse staff and the availability of the manager during the day. The staff spoken to all spoke positively about the care they provided to the service users. This was also collaborated by the service users and relatives spoken to who said the home provided excellent care and the care staff were very nice. One service user said he was shouted at by some nurse staff that he described as rude. The care staff spoken to said they received good standards of training and records seen suggested that staff had regular and updated training in areas that would enhance the care received by the service users. The home still needed to ensure a minimum of 50 of the care team obtained their NVQ level 2 in care; they were currently operating below that standard. The home had satisfactory recruitment procedures and the files inspected showed that the recruitment practices would protect the service users. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36, and 38. “Quality outcome in this area was adequate. The judgement was made using the available evidence collected and a site visit to the service”. Service users were provided with good leadership procedures that ensured Satisfactory management and administrative procedures were followed which resulted in a well run home and supported staff team. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 20 EVIDENCE: The home had made several changes in regards to the administrative and operational procedures that all spoke positively about in regards to bettering the care for service users. The records seen suggested that more and better recording of information had been promoted in order to protect the service users. The manager explained that the new procedures had enabled her to be more empowered in ensuring the service users admitted to the home were those whose needs could be met by the resources available. The administration of these processes had also been improved to ensure the care provided was more transparent and consistent for all the team to follow. Staff and relatives spoken to said the management of the home was open and transparent and they had the support and guidance when needed. The staff team said they had regular supervision and meetings and as a result were kept informed of changes on a regular basis. One aspect of health and safety for service users was identified in regards to the trailing of the call systems cords across the service users bedroom floors. This had been identified by the home and plans were in place to change the current system. The care plans did not show that risk assessments were carried out for the service users who were all at risk of falling. The home had satisfactory fire safety measures and place and staff spoken to said they had regular fire drills and training. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 21 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 2 3 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 18 3 2 x x x 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 2 Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 22 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 OP4 Regulation 15 (1) Requirement Arrangements must be made to ensure all service users are aware of the details of their care package and how it will be implemented. Arrangements must be made to ensure the care plans for the permanent service users are reviewed and updated on a regular basis. A record must be kept for all service users detailing their wishes in the event of their death. Previous timescale: 30/01/06 All service users must be given the opportunity to have satisfactory stimulation throughout the day. Previous timescale 30/01/06. Arrangements must be made to ensure the communal areas of the home and identified bedrooms with peeling wallpapers are redecorated. Previous timescale: DS0000033142.V288289.R01.S.doc Timescale for action 30/06/06 2. OP7 15 (1) 30/06/06 3. OP11 12 (1) (a), 12 (2) 30/07/06 4. OP12 13 (4) (b) 30/06/06 5. OP19 23 (2) (d) 30/08/06 Westlea Version 5.1 Page 23 30.10.05/30.03.06 6 OP24 12(1) Arrangements must be made to ensure the safety of the service users in their bedrooms with regards to trailing wires for call point systems. All staff must receive accredited training in the correct procedures of administering medication before they are allowed to administer medication to the service users. Previous timescale: 30.01.06 Arrangements must be made to risk assess all service users who may be at risk of tripping over the wires trailing in their bedrooms, until such time that they are removed. 30/06/06 7. OP30 18 (1) (a) (i) 30/07/06 8 OP38 13 (4) (b) 30/06/06 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 2. Refer to Standard OP2 OP30 Good Practice Recommendations Arrangements should be made to ensure all service users are provided with a contract that states the terms and conditions of their stay. Arrangements should be made to ensure a minimum of 50 of the care staff receive their NVQ level 2 in care qualification. Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Westlea DS0000033142.V288289.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!