Inspection on 24/02/06 for Westleigh

This inspection was carried out on 24th February 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

Westleigh 09/11/06

Westleigh 10/09/05

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 Inspection 24th February 2006 09:30 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 Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westleigh Address 17 Summerhill Terrace St George Bristol BS5 8HX 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) 0117 9031062 0117 9551271 Bristol City Council Mrs Sandra Delves Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th September 2005 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 24hour nursing but nevertheless do need medical interventions on a regular basis. There are currently four beds allocated for this service. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place midweek between the hours of 10am and 4pm. Evidence was gathered from: talking to/observing residents, talking to relatives, talking to the manager and one assistant officer, talking to and observing staff, talking to visiting health professionals, looking at the premises, examining records, policies and procedures. Westleigh currently operates four Intermediate Care beds. was occupied at the time of the inspection. One of the beds What the service does well: What has improved since the last inspection? Please see section below Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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 Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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 Information about the home provided to residents and their representatives has improved since the last inspection. However, minor 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 admitted to the intermediate care facility can be sure that their individual needs are met. However attention is needed to ensure that all residents’ needs are met including those live permanently at Westleigh. EVIDENCE: The Statement of purpose and service users’ guide in place for Westleigh are of a high and now contain information about the intermediate Care Service which started operating in February 2005. 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. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 9 It was noted that the statement of purpose stipulates that in exceptional circumstances and extreme cases people less than 65 years but not younger that 55 years can be admitted. This can only take place following an application to vary the age range, which must be agreed with the Commission For Social Care Inspection. This information must be made clear in the Statement of purpose and service users guide. The 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 but plans to admit another resident that day were in operation. During the course of the inspection the inspector had the opportunity to meet the two qualified nurses and a community care worker supporting the resident who was staying in the intermediate care bed and were busy planning for the admission of a second resident that day. All health professionals were very positive about the care provided at Westleigh and confirmed that communication with the management and staff team was very good. One Health professional said, “Care at Westleigh is exemplary. We have no concerns about the service at Westleigh”. A sample of needs assessments obtained prior to a resident being admitted to the intermediate care bed were seen on residents’ files. It was noted that they were up to date and accurate and included full details of the individual residents’ assessed needs. One of the residents seen receiving intermediate care was very positive about the support she had received from all the staff. She said that “she was in good hands” then went on to describe how she had lost her confidence after a fall and how the staff were helping her too become independent again. Two relatives seen visiting their relative who was receiving intermediate care said. They felt very positive about the care provided and that everybody had been very helpful. They also commented on how they had been kept informed about their relatives care. It was noted that the rooms allocated for residents who require intermediate care support are situated individually on the first floor of Westleigh interspersed with those rooms that residents are allocated when they are admitted to the home long term. During the course of the inspection it came to the attention of the inspector through discussions with a relative and a resident that they had concerns about the noise level from the rooms of some service users who have received intermediate care. This noise was a result of extra staff particularly at night and TV being used late at night. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 10 It was also understood that this resident had felt quite vulnerable on occasions as some services users who had been receiving intermediate care had at times become confused about the location of their room and had wandered into her room. Concerns were also raised about the high turnover of service users, which was in their opinion unsettling. It was understood that this information had not been raised with the manager. It was noted that a formal review had been conducted by Social Services and Health in August 2005 about the intermediate care service provision at Westleigh, but service users and staff who work at Westleigh who are not part of the intermediate care service had not been asked for their views about the impact of the intermediate care service on residents who live permanently at Westleigh. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Care plans and individual risk assessments continue to be 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 continue to be well met with evidence of good multidisciplinary working taking place on a regular basis. 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 DS0000036976.V280010.R01.S.doc Version 5.1 Page 12 During the course of the inspection the inspector had the opportunity to speak to one resident’s key worker at length about the support she had provided to this resident whilst he had been in hospital. The resident in question has longterm mental health needs. It was understood that the hospital staff had had problems meeting this resident’s needs despite a very detailed care plan being sent to the hospital from the home. The member of staff showed very good awareness of meeting this residents specialist needs with dignity and respect. The manager confirmed this at the time of the inspection. 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. One resident said, “The staff are never rude or patronising”. Another resident who said she had moved from another care home said “I am well looked after here. The staff are easy going. I cannot say anything against them. We have a laugh and a joke.” There was evidence in place to confirm that General Practitioner’s, psychiatrists, the mental health” in reach “service, 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. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This standard was not assessed on this occasion. They were found to be all met at the last inspection conducted on the 10th September 2005. EVIDENCE: Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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): 16,18 The complaints system in place is good which ensures that residents and their relatives continue to be confident that their concerns will be listened too and acted upon Attention needs to be given to the system in place for protecting residents from possible risk or harm to ensure that it is robust. 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 “ I would speak to an officer or the manager if I had any concerns but I am happy here.” A relative said, “My Aunt is very happy here. She could not be in better hands. All carers are wonderful. I have visited at different times and it is always the same. It is always clean….it does not smell. I would be informed if my aunt had a fall. I have never had to raise a complaint. However if I did I would know what to do.” Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 15 Another resident said, “The staff are good to us and there is entertainment every day. I cannot grumble”. Two residents seen in the dining room said “We like it here; the food is good. There is plenty of choice. If we had a complaint we would talk to one of the officers or our key workers.” Another resident in question said “I would talk to the manager if I had a complaint”. It was noted that 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. No Secrets in Bristol (Local authority Adult Protection procedure) is in place in the home. There was information to confirm that the management team and all staff members are currently in the process of attending adult protection training organised by Bristol City Council Safeguarding Adults Coordinators during the next few months. Prior to the inspection The Commission for Social Care Inspection had been notified about an allegation made about a member of staff that was currently being investigated under Bristol City Council complaints procedure. The inspector was updated about the situation during the inspection. During the course of the inspection it came to the attention of the inspector that an allegation had been made by another resident about another member of staff which was currently being investigated. The Commission for Social Care Inspection had not been informed about this second allegation and neither had a risk assessment been carried out to protect this resident or other members of staff. There was also no evidence to confirm that this allegation had been treated as a protection of vulnerable adults referral within Social Services and Health as outlined in the adult protection policy and procedure NO Secrets in Bristol. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standard were not assessed on this occasion. They were all assessed at the last unannounced inspection conducted on the 10th September 2005 and were found to be met. EVIDENCE: Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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): These standard were not assessed on this occasion. They were all met at the last unannounced inspection conducted on the 10th September 2005 EVIDENCE: Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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): 37,38 Following the last inspection improvements have been made in respect of making the records available for inspection. However further attention is required to ensure that there are systems in place so that residents and staff health and safety are fully protected at all times. EVIDENCE: All records that must be available for inspection were accessible. However it was noted following the examination of the fire log that night care staff are not receiving three monthly fire safety training. All other health and safety checks were noted to be up to date and accurate. Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 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 2 X X X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X 3 2 Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? no 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 OP1 Regulation 6 Requirement The Statement of purpose must be very clear about the age range of residents that can be admitted The intermediate care service must be formally reviewed with residents who live at Westleigh long term, their representatives and the staff providing the care to those residents A risk assessment must be completed for all residents who wish to mange their own finances and arrangements made to protect that resident and members of staff All allegations of abuse by a member of staff must be reported to CSCI immediately All night staff must have three monthly fire safety training Timescale for action 31/05/06 2. OP6 24 (1) (a) 31/07/06 3. OP18 13 (b) 30/04/06 4 5 OP18 OP38 37 23(4)(d) 07/04/06 30/04/06 Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westleigh DS0000036976.V280010.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos 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 DS0000036976.V280010.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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