Inspection on 20/10/05 for Westleigh

This inspection was carried out on 20th October 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westleigh 14/06/07

Westleigh 24/01/06

Westleigh 10/02/05

Westleigh 05/10/04

Westleigh 11/01/04

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

CARE HOME ADULTS 18-65 Westleigh 109 Walton Road Stockton Heath Warrington Cheshire WA4 6NR Lead Inspector David Jones Announced Inspection 20th October 2005 10:00 Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 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 Westleigh DS0000027003.V254136.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 Adults 18-65. 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 DS0000027003.V254136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westleigh Address 109 Walton Road Stockton Heath Warrington Cheshire WA4 6NR 01925 860584 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) Warrington Community Care Ms Alison Edwards Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (18) Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of Service Users must not exceed 18 18 of the Service Users may be MD 18 of the Service Users may be MD(E) Date of last inspection 10th February 2005 Brief Description of the Service: Westleigh is a care home operated by Warrington Community Care that provides a long-term home for people who have suffered, or are suffering from an enduring mental illness. The care home is located in a pleasant and popular residential area of Stockton Heath and provides spacious and well-maintained accommodation. There are 18 single bedrooms, two of which are being used to provide double accommodation for two residents who wish to share. Four lounges including the main lounge, which is designated a non-smoking lounge. Thirteen WC’s, bathrooms and two shower rooms. The home is accessible to wheel chair users with lift access to the first floor. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on one day the 20th October 2005, over a four and a half hour period. Seven residents, one relative and four members of staff were spoken with during the inspection. We looked at some parts of the building, inspected medication systems, looked at some records and read the case notes of three residents. What the service does well: Westleigh House is well managed. It provides accommodation that is comfortable, spacious, homely and well equipped The home’s assessment and care planning processes are based on good practice. These involve the resident and their representatives in the continuing development of effective arrangements for care and support. Residents have opportunities for personal development, rights are promoted and staff support residents to become part of and participate in the local community. Family links and personal relationships are supported. Residents are satisfied with the standard of catering. Choice is offered with every meal, and likes, dislikes and special dietary needs are known and catered for. Visiting relatives are made welcome and residents are able to entertain their guests in private if they so choose. Staff are employed in appropriate numbers and work together as an effective team. The staff team is stable and is able to provide consistent packages of care and support tailored to meet the individual needs of each resident. Staff demonstrate a clear understanding of residents’ needs and enjoy good working relationships with visiting health and social care professionals. The majority of staff have achieved an NVQ in care at level 2 or above and there is a comprehensive staff training programme in place. Staff receive regular supervision and speak highly of the manger and the organisation stating that support is excellent. Effective recruitment procedures ensure the protection of residents. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 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 DS0000027003.V254136.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 5. New residents are provided with the information they need to make an informed choice about the home. Assessment and admissions procedures put the resident at the centre of decision-making and no resident moves into the home without having their needs assessed by a competent person. Residents sign a license agreement, which confirms terms and conditions. EVIDENCE: There is a revised statement of purpose and service users guide, which together provide appropriate information about the home and facilities and services provided. There have been no new residents within the last twelve months. However reading of case records and discussion with management, residents and staff indicates that residents move into the home in a planned way. The placing agency and senior staff assess their needs and they are encourage to visit and test drive the home before they make any decisions about moving in. Residents are provided with details of terms and conditions in a licence agreement. The licence agreement identifies the charges per week, the room to be occupied, grounds for termination of the agreement, and the period of notice required by both parties. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 9 Residents are placed at the centre of decision making throughout the procedure for moving in and their rights and responsibilities are recognised and respected. The vast majority of residents accommodated are over 50 years of age. However current registration conditions allow for the accommodation of people with a mental disorder from the age of 18 years and there is no upper age limit. It is a matter of concern that people with vastly differing needs could be accommodated together in one home. It is not the intention of the registered persons to accommodate such a broad age range of residents and it is noted that this is reflected in the revised statement of purpose and service users guide. Discussions with the area manager before the inspection confirmed that it would be appropriate to change the conditions of registration to make sure that they are consistent with the needs of the people the home intends to accommodate. It is agreed that people who are forty years of age or younger should not be accommodated. The Commission for Social Care Inspection proposes to make the appropriate variation to the home’s conditions of registration. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Detailed care plans reflect residents’ needs and aspirations. Risk assessment and risk management is central to the way the home is managed and the way residents are supported to make decisions about their lives. EVIDENCE: Care plans are developed from the assessment with the full involvement of the resident, where practicable. Each of the three care plans seen provide clear guidance and confirmation as to how the respective resident’s needs are to be met. Independence is encouraged and residents are enabled to make decisions about their lives with support and guidance from staff and other specialists where required. Staff help residents to take responsible risks by ensuring they have the information they needs to make balanced decisions within a risk management framework. Where staff intervention is required to help a resident achieve and maintain identified goals a goal plan is developed with the resident and his/her representatives where required. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Residents are encouraged to explore and take advantage of social, recreational and employment opportunities on offer in the home or local community. Personal relationships are supported and visitors are made to feel welcome in the home. The standard of catering is good. EVIDENCE: Support staff work with residents to help them to identify and take advantage of opportunities for personal development, education and occupation presented to them in the local community. A number of residents attend work placement schemes and others occupy themselves taking advantage of other community amenities. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 12 Discussion with relatives and residents confirms that residents are supported to maintain family links and relationships inside and outside the home. Visitors are made welcome and residents are able to entertain their guests in private, if they wish. Residents are able to develop and maintain intimate personal relationships and information and specialist guidance is provided to help with decision-making and plans for future development, where required. Residents are supported to develop independent living skills and if required the manager and staff will work with the multidisciplinary team to support the resident to gain higher levels of independence and rehabilitation. Residents advise that they enjoy the activities on offer in the home. These include art and aromatherapy classes, a music group, entertainers and visits to various places of interests including annual holidays. One resident said that she found the coach holiday she had been on the year before was two fast a pace to enjoy the scenery. The manager advised that this had been the unanimous view of all participants and other alternatives would be explored. All residents praised the standard of food. Individual likes and dislikes are known and catered for. Menus seen indicate that a varied and nutritious diet is on offer. Residents are routinely consulted on the quality of meals, standard of care and facilities and services provided. The home operates a system of “cluster meetings” whereby a deputy manager will meet on a regular basis with their identified group of residents to discuss any matters that are important to them. Minutes of the meetings are kept in the home. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Care and support is provided in accordance with residents’ needs and personal preferences. Staff enjoy good working relationships with health and social care professionals and know what action to take when a resident is unwell. Medicines are stored, administered and recorded appropriately. EVIDENCE: Staff were observed to interact with residents in an appropriate, sensitive and supportive manner. Information provided by visiting GP’s indicate that staff demonstrate a clear understanding of residents needs and work in partnership acting on and incorporating specialist advice in the respective resident’s care plan. Discussion with the manager and reading of correspondence and residents’ records indicates that the home also enjoys excellent working relationships with mental health care professionals. Reviews are held on a regular basis. Residents speak highly of the staff team and are appreciative of the support they receive on appointments with health care professionals. It is clear that staff monitor residents’ health care needs and take appropriate action when needs change or residents are unwell. A medications check found that medicines are stored, administered and recorded appropriately. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Arrangements for the protection of residents and for making complaints are appropriate. EVIDENCE: The home’s complaints procedure provides appropriate guidance and information as to how to make a complaint. Information provided indicated that complaints no had been received since the last inspection. Robust procedures for responding to suspicion or evidence of abuse or neglect are in place including whistle blowing as in accordance with the Public Interest Disclosure Act 1998. Information provided by the manager indicates that all senior staff and a number of others have received training in the implementation of adult protection procedures. Other staff have received guidance and information on adult protection procedures and further training needs identified by the home’s staff appraisal systems will be addressed in due course. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The premises are suitable for the home’s stated purpose. It is accessible, safe, comfortable and clean throughout. Policies and procedures are in place regarding infection control and hygiene, including specific laundry procedures. EVIDENCE: Residents live in comfortable well-equipped accommodation. Westleigh is located in the residential area of Stockton Heath. It is a large detached property that has been extended to provide appropriate living space for the 18 residents. There are gardens for residents to enjoy, which include a large ornamental pond. The manager advised that a risk assessment had not been completed in respect of hazards that may be presented by the pound to certain residents. See recommendation 1. The home is kept clean by staff and residents who are responsible for keeping their bedrooms clean and tidy. Systems are in place regarding food hygiene and infection control. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 36. Residents are supported by an effective, competent and qualified staff team. Staff are employed in appropriate numbers and residents are protected by the organisations thorough recruitment procedures. EVIDENCE: Eight of the home’s 11 support staff have a qualification at NVQ level 2 or above in care. All staff are required to complete a programme of induction training and the organisation has formed links with Warrington Borough Council, Social Services to access their TOPSS approved induction and foundation training. Twelve staff hold a current first aid certificate. Staff are employed in appropriate numbers with a minimum of two support workers including a Deputy Manager on duty at any time. At nighttime there is one wakeful member of staff on duty supported by a Deputy manager “sleeping in” on call. The manager ordinarily works office hours but will vary her shifts to meet the needs of residents’. In addition each of the three Deputy managers work a six flexible shifts each month. These shifts enable staff to support residents on visits to health care professionals and supported activities in the community. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 17 Reading of staff recruitment files confirms that all appropriate references and recruitment checks are completed before an individual starts work. The manager provided written confirmation that satisfactory Criminal Records Bureau checks have been carried out. The staff team is stable with very little staff movement. Staff presented as knowledgeable and confident and spoke highly of the support provided by the manager and colleagues. Morale is high and the staff team have received awards for low levels of absenteeism. Training opportunities are said to be excellent. The organisation is supporting and encouraging its deputy managers to achieve NVQ Level 4 in care. Supervision is provided every three months and staff appraisals are undertaken twice a year. There are no formal arrangements for the induction of agency staff. However the manager advised that she is currently working with other senior staff in Warrington Community Care to develop appropriate arrangements and documentation. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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, 38, 40 and 42. The registered manager is qualified, competent and experienced to run the home. The management approach is open positive and consistent with the needs of residents. Staff have access to a comprehensive set of polices and procedures. Arrangements are in place to assure the health and safety of residents and staff. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and meet its stated purpose aims and objectives. The manager is a qualified nurse SEN (M) and has achieved NVQ level 4 in management and care. Residents’ benefit from a well run home. Residents speak highly of the staff and management teams indicating satisfaction with care facilities and services provided. Comment cards indicate that the majority of residents like living at the home, all are well cared for and their privacy is respected. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 19 The processes of managing the home are open and transparent. Staff indicate that the manager communicates are clear sense of direction and is supportive and involving in approach. Each Deputy manager holds small group meetings that are designed to help residents voice their views as to the conduct of the home. Warrington Community Care seeks to ensure the health and safety of all employees and residents. Risk assessment and risk management are central to the conduct of the home. The registered manager ensures that risk assessments are carried out for all safe working practice topics and significant findings are recorded and reviewed. The pound in the garden may present hazards to certain residents. The registered persons should complete a hazard analysis and risk assessment exercise regarding the pond to make sure that any potential hazards are identified and controlled. See recommendation 1. Routine maintenance checks are carried out on all appliances and services, however there was no record as to when the electrical wiring and hot water systems (Legionella) have been tested. See requirement 1. Westleigh DS0000027003.V254136.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westleigh Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 2 X DS0000027003.V254136.R01.S.doc Version 5.0 Page 21 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 Standard OP38 Regulation 23 Requirement The registered persons must ensure the home’s electrical wiring and hot water systems are inspected and serviced in accordance health and safety requirements. Timescale for action 30/11/05 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 OP38 Good Practice Recommendations The registered persons should conduct hazard analysis in respect of the pond and if required a risk assessment should be completed to identify any necessary control measures. 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