Inspection on 18/07/06 for Westleas

This inspection was carried out on 18th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westleas 12/01/09

Westleas 03/03/08

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Westleas 47 Earls Avenue Folkestone Kent CT20 2HB Lead Inspector Wendy Jones Unannounced Inspection 18 July 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 Westleas DS0000066037.V300082.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. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleas Address 47 Earls Avenue Folkestone Kent CT20 2HB 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) 01303 242784 Kestrel Care Limited Sita Bhadye Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Westleas is a residential care home, providing care for up to twenty people over the age of 65 years. The home is situated in an avenue, close to the Leas area of Folkestone. There is a mainline railway station and local bus routes nearby. The home has a statement of purpose that gives information about their service. A copy can be obtained from the home. Currently the scale of fees is between £303.25 and £500. Hairdressing, chiropody, newspapers and toiletries are at an additional charge. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Wendy Jones, Regulatory Inspector, carried out this key inspection. It was carried out over a period of time and concluded with a site visit to the home between 10:00am and 2:30pm on 5 July 2006. A range of evidence has been used to inform this report and judgements have been made based on this evidence. Evidence used includes concerns, complaints, allegations and other information received, reports of incidents and deaths that have occurred since the new owners took over the home, a tour of the home, inspection of some records, comments received from GPs, residents and their relatives and discussion with the owner, residents and staff. What the service does well: What has improved since the last inspection? This is the first inspection since the new owners took over in February 2006. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 6 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. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-6 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective residents have all the information they need to decide whether the home is for them. EVIDENCE: The home changed ownership in February 2006. The Commission has received a new statement of purpose and service user guide that show these changes. These documents contain all the information required to help prospective residents make a choice about whether to move into the home. They are also able to spend time there. The service user guide contains a contract that covers all the key aspects of the home including fees. Files and care plans were seen for three residents that had moved into the home since the new owners had taken over. They identified any special needs Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 9 and contained pre-admission assessments by the home and other professionals including care management. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents’ general health and personal care needs are met. EVIDENCE: Care plans were seen for one resident who was living in the home before the change of ownership and three since the change. A new care planning tool has been introduced which makes the care plans clear and easy to follow. Needs and risk assessments were comprehensive and clearly identified the need or risk. They outlined the action staff are to take to meet these needs and reduce or remove any risk. Care plans had been reviewed monthly and comprehensive daily records were being kept. They also contained details of when the resident had seen their doctor, or district nurse and of optician, dentist etc appointments. Some residents said that they were waiting to see the chiropodist. Medication records were clear, up to date and accurate. The owner said that only she and senior staff are responsible for administering medication. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 11 The medication cupboard is very small but medication was being stored appropriately in a locked trolley and on shelves in the cupboard. Information received prior to the site visit showed that staff had recently received medication training from Boots. Records seen confirmed that this had taken place. Residents commented that the staff were polite and caring and “like friends”. Relatives of residents commented that the “staff are endlessly patient and always supportive” and “… has settled in very quickly… is so happy and very well looked after”. The staff on duty at the time of the site visit clearly understood the needs of the residents and treated them with respect and courtesy. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service The daily routines and activities provided meet residents’ needs and are flexible. Residents keep in contact with their family and friends. EVIDENCE: The owner has put together a list of activities and interests that the residents have. She advised that she intends to use this information to build upon the existing activities that are provided. Information sent to the Commission before the site visit listed a range of activities that are provided for the residents including bingo, table games, gentle exercise, church visits and musical afternoons with outside entertainers. Residents said that their relatives and friends visit them regularly. A number of people came to see residents during the site visit. Relatives said they were welcome to visit at any time and can visit their friend or relative in private if they want to. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 13 Copies of menus had been received before the site visit. These and records in the kitchen of what residents had eaten each day showed they have a variety and choice. The cook was familiar with the likes and dislikes and any specialist diets of the residents. Residents said they enjoyed the food and had plenty. Some residents had the midday meal in the dining room. Staff brought others theirs in their room. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 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 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives’ complaints are taken seriously and investigated. Staff will take the correct action to safeguard residents from abuse. EVIDENCE: Information received before the site visit stated that there had been two complaints received by the home since the change in ownership. These had been investigated within 28 days. The complaints procedure gave details of how to complain and the process and timescale that any investigation will be completed in. It also contained details of how to contact the Commission. The owner is putting together a comprehensive training programme. One of the subjects planned for the near future is the protection of vulnerable adults. However, staff were clear about what to do if they suspected a resident was being abused. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 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): 19 –21 and 23 - 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and comfortable home with private and communal rooms that meet their needs. EVIDENCE: All areas of the home were attractively decorated. They were pleasant and reasonably airy despite it being a very hot day. Relatives commented that “during the recent change of ownership standards of cleanliness had temporarily declined, however this problem appears to have been resolved.” On the day of the site visit the home was clean and hygienic and there were no unpleasant odours. There is a shaft lift for residents whose bedrooms are on the upper floors. There is a lounge with television, radio and books for residents to enjoy and Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 16 comfortable seating. The dining room is clean and pleasant and has seating for sixteen residents to eat at one time. There is a large well-established garden at the rear. It has a patio and a large grassed area with benches and chairs. Residents’ rooms were individual to them and met their needs and tastes. They had their own personal items including photos, pictures, televisions etc. There are sixteen single rooms and two double rooms. Two of the single and both of the double rooms have en suite facilities. There are three communal bathrooms, one on each floor. These had been recently refurbished and were clean and hygienic. In addition there are four communal toilets. The owner has plans to improve the laundry and replace the current washing machine with a larger, industrial size machine. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 - 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment procedure. They are supported by staff who have the skills to meet their needs. EVIDENCE: At the time of the site visit the owner, two care staff, the cleaner/maintenance person and the cook were on duty. This was clearly enough staff to meet the needs of the 13 residents in the home at this time. The owner explained that there would usually be a senior carer on duty who takes responsibility for giving residents their medication. However, at the time of the site visit, due to staff shortages, the owner was taking on this role. Relatives feel there are sufficient staff on duty and commented “… is very well looked after and I am very pleased with the care and attention … gets from the staff of Westleas” Currently five care staff have achieved an NVQ in care. Three further staff are due to start NVQ 2 or 3 in September 2006. This will mean that more than 50 per cent of the staff team will be trained. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 18 Staff files for three staff who had been recruited by the current owner were seen. They contained all the information needed including CRB checks, two references and application forms. They had all completed, or were in the process of completing, a structured and appropriate induction. Records of these were seen which had been signed and dated to confirm when each section had been satisfactorily completed. Details of training planned for July and August 2006 in manual handling and infection control were displayed on a whiteboard in the staff office. Since the owner had taken over all staff had received medication and fire awareness training. She confirmed that further training in adult protection, food hygiene, first aid etc. is also planned. The owner has introduced a staff handbook so that staff are clear of their responsibilities and residents are well cared for. Residents said that “staff are endlessly patient and always supportive”. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 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): 3 – 33 and 35 - 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-managed home that is run in their best interests and safeguards their rights. EVIDENCE: The owner is a qualified mental health nurse with experience of management within the NHS. She has made good progress in reviewing and improving the services provided to the residents and has plans for further improvements. The home was well run and the owner and staff were welcoming. Staff said that they enjoyed working at the home and “there is a good team spirit”. They said that they feel well supported by the owner and have the skills and Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 20 resources they need to do their jobs well. They were keen to develop further and were looking forward to attending further training planned. The owner has a quality assurance system that will be used each year to get the views of residents and their families about the home. She advised that residents meetings have been set up and that residents would like them to be held on a monthly basis at the moment. Notes of a meeting that had been held on 1 July 2006 confirmed this. The owner has reviewed or introduced new policies and procedures for the home to ensure it is run in the best interests of the residents. Staff have been given copies of these and they have signed and dated to confirm they have read and understood them. The owner also said that some procedures had been covered in team meetings and supervision. Notes of these confirmed that this had happened. Information received before the site visit stated that the home does not act as appointee for any residents. Their relatives or care manager deal with their finances. The owner confirmed that the home does not keep cash for residents. Supervision records were seen in staff files. These showed that staff are receiving regular formal supervision. A new member of staff explained that they had just completed their induction period and was due to have supervision with the owner that afternoon. Staff said that they had all been on fire awareness training recently and a fire drill had taken place the week before. They were clear and confident about what to do if the fire alarm sounded. Training records showed that staff have attended fire awareness training. Only 2 staff are currently first aiders. The owner said that she is organising a first aid course for the near future so that sufficient staff have been trained. Information received prior to the site visit showed that all relevant maintenance and checks have been done and are up to date. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 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 3 3 Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP9 Good Practice Recommendations Examples of the signatures of staff trained and authorised to give residents their medication should be available for reference. Photographs of residents should be available for staff to confirm that they are giving residents their correct medication. Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Westleas DS0000066037.V300082.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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