Inspection on 10/09/05 for Westleigh

This inspection was carried out on 10th September 2005.

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

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

Other inspections for this house

Westleigh 09/11/06

Westleigh 24/02/06

Westleigh 10/11/04

Westleigh 14/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Westleigh 17 Summerhill Terrace St George Bristol BS5 8HX Lead Inspector Sandra Gibson Unannounced 10 September 2005 10:45 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westleigh Address 17 Summerhill Terace St George Bristol BS5 8HX 0117 9031062 0117 9551271 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bristol City Council Mrs Sandra Delves CRH-PC Care Home 40 Category(ies) of OP Old age [40] registration, with number of places Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 10th /11th November 2004 Brief Description of the Service: Westleigh is a local authority care home managed by Bristol City Council and is located in the residential area of St.George. It provides accommodation for up to 40 individuals and is registered to provide personal care for older people aged 65 and over. There are a number of communal areas with dining room, garden and patio area. The home is on two floors with lift and is fully equipped to meet the needs of residents. Westleigh is also the local authority care home in Bristol chosen to pilot the New Roles project/ Intermediate Care ; this is where individuals have needs of a medical nature which would otherwise be provided by community nursing services. A number of staff are due to undertake additional clinical training to enable them to provide low level care of a medical nature under the direct supervision of a nurse. The provision of such a service will, it is hoped, enable individuals who have care needs of this level to be discharged from hospital at an earlier date and in addition prevent their moving to a nursing home if their needs are such that they do not require 24hr nursing but nevertheless do need medical interventions on a regular basis. There are currently four beds allocated for this service. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Saturday between the hours of 10.45am pm and 5.15pm. Evidence was gathered from: talking to/observing residents, talking to two assistant officers/ talking to and observing staff, looking at the premises, participating in the communal lunch, examining records, policies and procedures Westleigh currently operates four Intermediate Care beds. There is an outstanding application for the variation of the registration of the care home to include the changed use of these beds. What the service does well: People moving to Westleigh can be sure that their needs can be adequately met due the standard of assessment completed prior to a prospective residents admission. Care plans and individual risk assessments are of a good standard ensuring that residents’ needs are fully identified and met and that they are treated with dignity and respect. The healthcare needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. The medication administration system in place is satisfactory. There are safeguards in place to protect residents. Residents are given the opportunity to experience a stimulating and varied life where various informal activities and outings are regularly made available. Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. Staff numbers at Greville are sufficient to meet residents’ needs. They are trained and competent to do their job which ensures that residents are well looked after. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5,6 Information about the home for residents has improved. However, attention is needed to ensure that new residents and their relatives can make informed choices about the home and that they can be sure their rights will be safeguarded. People moving to Westleigh can be sure that their needs can be adequately met. EVIDENCE: The Statement of purpose and service users’ guide in place for Westleigh were noted to be of a high standard, but there was no mention of the intermediate Care Service which started operating in February 2005. It was noted that there are four dedicated beds which are used by North Bristol Intermediate Care Service to facilitate the safe discharge of patients over the age of 65 from Bristol’s acute hospitals, and in particular from North Bristol Trust. It was noted that there is an outstanding application for variation for the change of use of these beds which must be urgently addressed to prevent legal action taking place. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 9 The inspector was informed that stays in Westleigh intermediate care beds are normally limited to 6-8 weeks, so assessment and care planning continue, to ensure service users are able to return home after this period, or are discharged to other appropriate accommodation. On the day of the inspection there was only one resident using this facility. A sample of needs assessments obtained prior to a resident being admitted to the home were seen on residents files. It was noted that they included full details of residents’ assessed needs. Residents admitted to the long term beds in the home have the opportunity to have a formal review with the support of their relatives within 4-6 weeks to ensure that the quality, facilities and suitability of Westleigh meets their needs. A review was due to take place before a recent placement was to be made permament. Two relatives confirmed this information during the course of the inspection. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Care plans and individual risk assessments are of a good standard ensuring that residents’ needs are fully identified and met and that they are treated with dignity and respect The health care needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. The medication administration system in place is satisfactory. There are safeguards in place to protect residents from harm. EVIDENCE: A sample of care plans and risk assessments were seen and it was observed that they were very clear well detailed and there that there was evidence in place to confirm that they were reviewed on a regular basis by the manager in consultation with the resident, their representative where possible and the resident named key worker. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 11 One resident told the inspector “I am very well looked after here they assist me with my bath and help me with my hair . They treat me with respect and do not shout at me”. The inspector observed the staff during the course of the inspection and noted that they had a good rapport with the residents. The staff used humour where appropriate in a relaxed polite respectful manner. There was evidence in place to confirm that General Practitioner’s, psychiatrists, district nurses, opticians, dentists and chiropodists are all contacted at the appropriate time. In the case of the Intermediate Care service it was also noted that the Rapid Response team are also involved with residents care. Records all confirmed that residents were assisted to attend hospital appointments where planned. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. A sample check of medication administered to residents was undertaken. It was noted to be satisfactory. It was observed that a community pharmacist audit had been conducted on the 29th July 2005. The inspector was informed that the recommendations made following the visit had subsequently been followed up. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The residents of Westleigh are given the opportunity to experience a stimulating and varied life where various informal activities and outings are regularly made available. Visitors are made very welcome and meals are well managed and provide daily variation, good nutrition and social contact for people. EVIDENCE: The inspector was informed that there is a programme of activities twice a day one hour in the morning and one hour in the evening (Monday to Friday) and once a day at the weekend in the evening. Care staff also work with individual residents during (key time). It was noted that individual key workers make themselves known to residents and family members. This was confirmed by several residents seen during the inspection. Live entertainment which is usually musical is held in the home every two to three months. There is a diary of activities available to view on the notice board on the door leading in the dining room. This information was confirmed by the photographs in the home of residents staff involved in activities such as V.E. Day and a Summer BBQ. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 13 A couple of residents talked about visiting the bar which is open each evening. The inspector heard about regular outings to places of interest such as Brean and Weston- Super-Mare. The inspector observed the game of Bingo that was held in the dining room after the communal lunch. A couple of residents spoke about the library facility which is accessible to all residents as it is situated in one of the hallways on the ground floor. The inspector heard how the books are changed every six weeks. All residents observed during the inspection looked relaxed with the staff providing their care who were observed to respond to the residents in a respectful unhurried manner. Menus were inspected and were found to be balanced and appetising. Meal times are also flexible enough to accommodate individual preferences. A couple of residents choose to eat in their bedrooms. The inspector joined in the relaxed communal lunch. Residents were seen being assisted by staff members to make choices about the meal they wanted and one resident talked about her diabetic diet. The five residents the inspector sat with confirmed that they liked the food and that there was plenty of choice available. The residents confirmed that they are provided fresh fruit and vegetables on a regular basis. The residents confirmed that the provision of in between drinks and snacks are very good and that their families are made very welcome when they visit. One resident stated that if they wish to relatives can stay for a meal. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents and their relatives are confident that their concerns will be listened too and have been made aware of the complaints procedure. Arrangements for protecting residents from possible risk or harm is good. EVIDENCE: Relatives and staff confirmed that they were comfortable talking to the manager or one of the management team about any concerns. Residents were seen actively seeking out the members of the management team on duty that day with any concerns they had. One resident said “If I had a complaint I would talk to one of the officers or my key worker. Another resident in question said “I would talk to the manager if I had a complaint”. No complaints have been received either by the manager, the complaints officer for Bristol Social services and Health or The Commission for Social Care Inspection since the last inspection. Unfortunately there were despite the inspection taking place at a weekend there were no relatives to confirm this information No Secrets in Bristol (Local authority Adult Protection procedure) is in place in the home. The inspector was informed that there is a programme for the management team and all staff members to attend adult protection training during the next few months. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26, Westleigh continues to be a clean, comfortable, safe home .There has been an improvement in the space and health and safety facilit since the last inspection which ensures that residents are kept safe from harm. EVIDENCE: The inspector was updated about the changes in the environment since the last inspection which include increased office space for staff and records held for residents, there are new disabled toilet facilities/ updated shower facilities in place, a new lift has been installed , new windows and a fan have been fitted in the laundry and the automatic door closure system to meet fire safety legislation is now in place . Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 16 In general, the environment is well maintained and suited to residents needs. Wetleigh is decorated and furnished to a standard that creates a comfortable homely atmosphere despite it being a purpose built building. There is a programme of redecoration and refurbishment to further improve the environment. There are a number of small lounges through the home in the care home which residents were seen using and appeared comfortable and relaxed. The home smelt fresh and the rooms were cleaned to a high standard. Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and furniture. The toilet and bathroom facilities are sufficient to meet the needs of the residents. The garden at Westleigh is maintained to a high standard. This is done with the assistance of one of the residents who is also caretaker of the greenhouse where he grows various plants, including tomatoes. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 The staff at Westleigh are employed in sufficient numbers to meet the residents’ needs. They are trained and competent to do their job which ensures that residents are in safe hands at all times. EVIDENCE: The staffing levels on the day of the inspection were satisfactory for the both the long term beds and the intermediate care facility. There are currently a couple of vacancies for care assistants posts. The inspector was informed that the permanent staff are offered extra hours to fill these gaps. It was noted that a member of staff had a recently transferred from another Local Authority Home which was due to close. On the day of the inspection the care staff on duty were all permanent. There is a programme of statutory training which includes basic food hygiene, first aid, manual handling and Protection of vulnerable Adults. Communication between residents and staff was noted to be very good and all staff observed were very sensitive to residents’ needs and spoke with respect and understanding of residents needs. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 18 Training in this care home also includes dementia care training, mental health training and loss and bereavement. It was also noted that the staff team are making excellent progress with NVQ training. Several members of staff have already completed NVQ 2 and many are working towards NVQ3 as the home is a pilot for this level of training due to the increased skills and expertise required to care for the residents who are admitted to Westleigh for intermediate care provision.. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,37,38 Residents live in a home is which managed efficiently by an experienced manager, deputy manager and a team of assistant officers Attention is needed to improve the availability of records at inspection to ensure that residents and staff health and safety is fully protected at all times the home. EVIDENCE: The management of the home is currently working well with the support of the manager, deputy manager and assistant officers. This information was confirmed by two assistant officers seen at the time of the inspection and the team manager through monthly reports sent to The Commission for Social care Inspection. This information was also confirmed by the members of staff and residents seen at the time of the inspection. There are regular staff meetings held in this home to which all staff including the night staff are invited. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 20 All records including the fire log seen during the course of the inspection were noted to be up to date and accurate. However, it was not possible to check the fire safety training as all records of training are held on individuals file. This is good practice, but a copy of the information must also be held with the fire log and made available for inspection at any time. Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x x 3 3 Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 1 1 Regulation 6 5 Requirement The Statement of purpose must be regularly reviewed and kept up to date A request for a variation in registration must be submitted to the Commission for Social Care Inspection All fire safety training records must be kept with the fire log and be available for inspection at any time. Timescale for action 10th Novemeber 2005 10th November 2005 10TH November2 005 3. 38 17(2) 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 Good Practice Recommendations Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 Westleigh D56_S36976_Westleigh_V248018_Stage 4.doc Version 1.40 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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