Inspection on 06/12/05 for Westlea

This inspection was carried out on 6th December 2005.

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 01/06/07

Westlea 20/04/06

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 6th December 2005 09:00 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.V268786.R01.S.doc Version 5.0 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.V268786.R01.S.doc Version 5.0 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.V268786.R01.S.doc Version 5.0 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. 4th August 2005 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 Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 5 Luton and Dunstable Hospital that used the beds to place service users. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out 4 months after the last inspection and lasted for the duration of 4.5 hours. The registered manager was temporarily moved from the home and another Luton Borough Council manager was managing Westlea. The acting manager was off sick on the day of the inspection. The inspection process was enabled by one of the team leaders and the area manager who joined the inspection in the latter stages. The inspection was carried out on the 6th of December 2005. The inspection process followed a case tracking methodology where 3 of the 4 service users in the home were chosen to case track. As a result their files were inspected in detail and where possible service users were spoken to about the standards of care they received from the staff in the home. The inspection report also reflected the views of the care staff, the management team and external professionals to the home. On this occasion there were no visitors available to speak to on the inspection. The home was undergoing a large investigation and as a result had only just received the authority to commence admissions. It was for this reason that only 4 service users were available to speak to on the day of the inspection. This report should be read in conjunction with the last inspection report to gain an understanding of the homes overall performance throughout the inspection year. In the last report some standards were assessed and were met and as a result they may not be assessed in this inspection report. What the service does well: The home was registered to provide care to service users requiring rehabilitation and intermediate short term care with limited residential placements. The care staff along with the help of various external professionals including the PCT provided satisfactory standards of care to various service users which had enabled many service users to maintain and maximise their independence, resulting in them being able to live in their own homes. The service users spoken to said their needs were totally looked after, a service user said she was comfortable and described the home as “First rate”. The staff treated them with total respect and they were very supportive and good. One service user said the staff were “ Marvellous”. All the service users spoke about the generosity of the meals they received and felt that the catering department was “First class”. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 7 The care staff said they were happy to work in the home and felt that the service users received good standards of care. From observation the service users appeared happy and contented and the staff team seemed dedicated to ensuring the service users needs were met. It appeared that the failures in the home resulted from proper implementation of systems in the organisation. What has improved since the last inspection? What they could do better: The home had identified through the recent complaint that there were failures in some of the policies and procedures available and their multi- disciplinary recording systems. The home had therefore addressed the identified areas that needed to be changed. These included better care practices to be offered from the care team, better medication procedures to prevent harm to service users, better recording of information and improved communication systems. It was identified in the inspection that close monitoring of these procedures was still in operation. However service users expressed their concerns that they were still suffering from elements of abuse. The home also needed to ensure that all the health care needs of the service users and their wishes are documented. Service users expressed their concern that they were bored due to the lack of activities offered to them from the staff group. There was an atmosphere of low staff morale and the relationship between the care staff and external professionals appeared strained. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 8 Their was also a need to ensure a minimum of 50 of the care team achieve their NVQ level 2 in care qualification. The commission would like to thank the service users, care staff, nurse team, external professionals, team leaders and the area manager for their cooperation in the inspection process. 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.V268786.R01.S.doc Version 5.0 Page 9 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.V268786.R01.S.doc Version 5.0 Page 10 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): 3 and 6. The processes for ensuring the needs of service users are adequately assessed were being reviewed and the home have had no new admissions for several weeks, as a result it was not possible to identify if the needs of the service users were satisfactorily identified and if the home would be able to meet the needs of the service users. EVIDENCE: The home was in the process of changing the assessment policies and procedures. There was evidence to suggest that this would be comprehensive and would provide the home with the opportunity to ensure they would be able to meet the needs of the service users before admission but this could not be assessed as it was not yet implemented. The current permanent service users had full assessment of needs but this was not consistent for the other two service users in the home for a temporary stay. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 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): 7,9,10 and 11. Satisfactory processes were in place to ensure some service users received good standards of care through their care planning, medication and health care procedures, as a result the service users were in safe hands. The home had a death and dying policy but further development was needed to ensure the wishes of the service users are recorded in the event of their death. EVIDENCE: The home had made improvements to their care planning procedures and those inspected appeared satisfactory. It was apparent that the permanent service users had more detailed care plans. The temporary service users care plans were sent to the home from social services and the home had not ensured they were made specific in ensuring staff knew what was expected of them. One example of this was a service user commented that a staff member refused to perform personal care to her, on observation her care plan did not record how this should be done. There was no evidence that the home had received these service users care plans. The care plans however, showed that various entries were recorded when external professionals carried out pieces of Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 12 work with the service users and as a result the health care needs of the service users were being addressed. Qualified nurses were carrying out the administration of medication. The care staff in the home were scheduled to receive training on administering medications. However it was the team leaders who carried out this task in the past and no formal training was organised for them. The area manager said this would be done before the team leaders can resume their responsibilities with regards to administering medication. Service users spoken to said they were treated with respect and dignity but two service users commented that some care staff were not always good to them, one said that care staff had taken away her food before she had finished eating and another said a care staff refused to perform much needed help in personal care. A service user commented that their was a need for more care staff as she had to wait a long time to get things done, it had improved she commented, but this could be because there are 4 carers to 4 service users and the work load was not as intensive. The home had a death and dying policy but their procedures in regards to recording the wishes of the service users in the event of their death needed to be improved. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 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 The opportunities for engaging in social activities were poor and as a result service users were bored. EVIDENCE: Service users spoken to said they were bored because there were limited opportunities for them to engage in activities. Service users were observed to be sitting in their bedrooms for the duration of the inspection. They commented that care staff would speak to them and they were able to have rehabilitation programmes. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. Satisfactory processes were in place to ensure the service users and relatives could confidently complain or report a suspected abuse. EVIDENCE: The home have had a major complaint since the last inspection which questioned the caring practices offered to service users, as a result various external professionals have been investigating the complaints and were due to complete their investigation soon. The home had also reported some areas of concerns under the Protection of Vulnerable Adults (POVA) policy and was still undergoing investigations in these areas. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 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 the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 16 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. The home had good processes in place to ensure the safety of the service users through their recruitment procedures, as a result service users were in safe hands. The home needed further development to ensure the numbers of staff are adequate to meet the needs of the service users and that they are trained and competent to do their job. EVIDENCE: The home had satisfactory levels of staffing on the day of the inspection but the home was registered to meet the needs of 28 service users. The care staff and service users spoken to said at present the levels of staff were sufficient but it will not be when the home has full occupancy. The area manger commented that they were in the process of reviewing the current staffing levels. The home had satisfactory recruitment procedures and the files inspected suggested that the authenticity of all carers were established before they commenced their employment. The home had identified various aspects of training, and care staff had embarked on several training opportunities in the past few weeks. Staff spoken to said they had received training in Manual Handling, POVA (Protection of Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 17 Vulnerable Adults) and Medication. The areas manager presented a detailed number of courses scheduled for staff to undertake further training in the near future. These areas of training included medication, record writing, diagnosis assessment of service users etc. There was a need for the further training to ensure more staff receive their NVQ level 2 in care. Currently, only 10 of the 29 care staff have this qualification. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 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 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): 37 and 38. The home had good processes in place to ensure service users safety was not compromised through their recording systems and health and safety procedures, as a result service users safety and welfare were protected. EVIDENCE: The home had improved on their policies and procedures and as a result better recording systems were in place to further protect the welfare of the service users. The home had a health and safety policy and satisfactory procedures were in place. The home was in the process of installing a new shaft lift and this was being carried out in a safe manner, service users safety was considered. The home also had risk assessments in place to protect the service users and visitors to the home, while the work was being carried out. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 3 3 Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 20 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 OP3 Regulation 14 (1) Requirement Arrangements must be made to improve the pre- admission assessments to ensure a comprehensive assessment of need is carried out before admissions are received in the home. Arrangements must be made to ensure all short stay service users have full and comprehensive record of all care interventions to be carried out. A record must be kept for all service users detailing their wishes in the event of their death. All service users must be given the opportunity to have satisfactory stimulation throughout the day. Arrangements must be made to ensure the communal areas of the home and identified bedrooms with peeling wallpapers are redecorated. Previous timescale: 30.10.05 Arrangements must be made to ensure a minimum of 50 of the care staff receive their NVQ level DS0000033142.V268786.R01.S.doc Timescale for action 30/01/06 2 OP7 15 (1) 30/01/06 3 OP11 12 (1) (a), 12 (2) 13 (4) (b) 30/01/06 4 OP12 30/01/06 5 OP19 23 30/03/06 6 OP30 18 (1) (a) (i) 30/03/06 Westlea Version 5.0 Page 21 7 OP30 18 (1) (a) (i) 2 in care qualification. All staff must receive accredited training in the correct procedures of administering medication before they are allowed to administer medication to the service users. 30/01/06 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 OP27 Good Practice Recommendations Arrangements should be made to review the staffing levels of the home to ensure they are satisfactory in meeting the needs of the service users. Westlea DS0000033142.V268786.R01.S.doc Version 5.0 Page 22 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.V268786.R01.S.doc Version 5.0 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. 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!