Inspection on 14/07/05 for Westley Court Nursing Home

This inspection was carried out on 14th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westley Court Nursing Home 11/06/08

Westley Court Nursing Home 24/01/07

Westley Court Nursing Home 11/01/06

Westley Court Nursing Home 22/11/04

Westley Court Nursing Home 27/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Westley Court Nursing Home Austcliffe Lane Cookley, Kidderminster Worcestershire DY10 2RT Lead Inspector Mandy Burton Unannounced 14 July 2005 08:10 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. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westley Court Nursing Home Address Austcliffe Lane, Cookley, Kidderminster, Worcestershire DY10 2RT 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) 01562 852952 01562 822958 Alpha Health Care Limited Mrs Gillian Hall Care Home 30 Category(ies) of PD(E) Physical disability both genders- over 65 registration, with number (30) of places OP Old age both genders (30) PD Physical disability both genders (5) TI Terminally ill both genders (3) Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That service users accommodated within the category of PD are aged 40 and above. 2.The home may accommodate one named service user over 55 with a learning disability . Date of last inspection 22 November 2004 Brief Description of the Service: Westley Court is a modern, purpose built nursing home, which is situated, in an attractive rural setting adjoining the main Kidderminster to Wolverhampton Road. The home is registered to accommodate a maximum of 30 residents in single room provision, with en-suite facilities. The rooms are situated on the ground and first floor with a connecting lift. A communal lounge/dining room is available on the ground and first floor. Westley Court Nursing Home is part of a group of homes owned by Alpha Health Care Ltd. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 08.10am. It took place over a period of 7 hours. The main focus of this inspection was to assess care practice and to review progress made by the home to address requirements made at the previous inspection. on 22.11.04. It was not possible on this occasion to review all previous requirements and these will be re-evaluated at the home’s next inspection. A partial tour of the home took place and a selection of care and staff records were examined. During the course of the inspection seven residents, and ten members of staff were spoken to. What the service does well: 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. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 6 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 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 7 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, 2, 3, 4 and 6 Some improvements are needed to update information for prospective residents, in order to ensure they are aware of what they can expect should they wish to move into the home. Residents’ individual needs are assessed prior to them moving into the home in order to identify the care and the services required when they move into the home. Facilities and services available to residents admitted for rehabilitation are good, which enables them to regain confidence and maintain independent living skills and prepare to return to their own homes. EVIDENCE: Since the last inspection some work has taken place to update information contained in the Statement of Purpose, and a separate portfolio is being developed which will eventually contain details of all staff employed in the home, and their relevant qualifications and experience. All staff will have the opportunity to contribute to the documentation. Further effort is necessary to Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 8 complete these records and to ensure all documentation relating to the former National Care Standards Commission is updated. No action has taken place to update the home’s service user guide as requested at the previous inspection. An up to date copy of a resident’s terms and conditions of occupancy and the latest inspection report should be included to ensure all residents are able to make an informed decision whether to move into the home. During this visit terms and conditions of occupancy were seen relating to three residents. Documentation did not meet the standard required, some information regarding the home’s registration was out of date and there was no record of the room to be occupied by each resident. There was however some written evidence to show that contracts had been discussed with the residents concerned or their representatives. All residents are assessed fully by a trained nurse prior to their admission to the home to ensure the home is able to meet their needs. Staff were observed during this visit discussing a resident due to be admitted to the home and arranging any support services/specialist input that may be necessary for when they arrive. The home has a contract with the Primary care Placement Scheme, which enables 5 residents to be admitted to a designated rehabilitation unit within the home, on the first floor on a short-term basis prior to being discharged home. The unit has a designated team of staff to care for residents, although the understanding has always been that these staff do provide care and support to residents on the nursing unit when time allows. Physiotherapy is available to these residents as prescribed and equipment made available to promote activities of daily living. There was some evidence during this visit that the needs of residents in the nursing unit were not being appropriately met. During the morning, an alarm call sounded from a first floor nursing room, a carer from the adjoining rehabilitation unit came and looked at display panel and went away. When challenged the carer said it was a call on the nursing unit and that they were working on the rehabilitation unit. When asked if they normally respond to calls, the carer said they would, but they suspected that the resident concerned probably just required assistance with washing. The carer was advised that the call may well be urgent and was asked to attend. Resident spoken to referred to long delays in waiting for staff to assist them. The lack of up to date records in relation to staff training (see findings in relation to standard 30) does not provide assurance that staff in the home have the skills and knowledge to meet the needs of residents in their care. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 9 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, and 10 Care planning and healthcare systems in this home are not consistent. Failures to ensure records reflect the acute needs of some residents admitted to the home and to ensure records are updated when changes occur places residents health and welfare at risk. The systems for the administration of medication are good but shortfalls in record keeping could lead to errors in administration and therefore place residents at risk. Resident’s right to privacy is being compromised by staff that fail to follow the homes procedures. EVIDENCE: Care plans were in place for each resident. The quality of care planning was variable. It was noted that care plans and risk assessments for a number for residents on the rehabilitation unit had been documented as part of the pre admission process. The plans had been implemented on the resident’s admission to the home. There was no evidence that any review had taken place until approximately one week later, to ensure needs on admission were consistent with those identified pre admission. This system is not satisfactory and has the potential to place residents at risk. In some cases pre printed care plans were being used. Those seen were not person centred and contained details of care that was not currently being provided. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 10 Care plans had not always been updated when there had been a significant change in the well being of residents. In addition to this care plans no longer relevant had not been discontinued, leading to some confusion as to the current care needs of that resident. Residents spoken to were not able to recall having seen their individual care plans, but there was some evidence that some residents or their representatives had countersigned care plans. Health care and moving and handling risk assessments had been completed for each resident. Risk assessments for some residents on the rehabilitation unit had been documented prior to their admission to the home, and records showed that these had not been reviewed until approximately a week after admission. The manager said that a care plan audit was being undertaken in order to ensure all care plans are appropriate. The quality of wound care management was variable. While some records were satisfactory others showed that reviews were not being carried out as required and plans lacked sufficient detail in relation to the condition of the wound and the care and treatment required. The records for one resident documented acute urinary problems. No fluid balance chart was in place to monitor the fluid intake and output for that person. When staff were asked if chart was in place, they said they were supposed to do one, but had not started it yet (approximately midday) and would start one immediately. Previous fluid balance charts were seen and recording on some of these was also inconsistent. The poor standard of recording had placed this residents healthcare at risk . Written records are kept of any visits or treatment by specialist health care professionals. Residents spoken to were satisfied with health care provision at the home. One resident made reference to the fact that residents on the nursing unit have to pay privately for physiotherapy and therefore any exercise available is limited. They stressed that opportunities for physical exercise are dependant on staff having time available to them to assist, and therefore this happens infrequently. Since the last inspection the home has agreed, with the primary care trust to be involved in a national project to implement a Gold Standard Framework, which is hoped will eventually result in a Good Practice Guide for nursing homes in relation to care provided to palliative care patients. The home is being given regular supported in this process by specialist Macmillan Nurses. Written policies are in place for the safe administration of medication. Medication administration records were seen, records seen were generally of a good standard but not all written additions or amendments to charts had been signed and countersigned. Safe systems were in place for the storage and administration of any controlled drugs. The dispensing pharmacy had inspected the home in June 2005 and the report showed no issue of concern were evident. The manager was Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 11 advised that personal risk assessments should be completed for residents prescribed Warfarin. The majority of residents in this home prefer to stay in the privacy of their own rooms rather than accessing communal areas. During the visit a member of staff entered a resident’s room without knocking, when the resident was asked if this happened frequently, the resident nodded and said ‘it’s bad’. This visit has also highlighted the need to raise awareness in the home in relation to confidentiality in relation to the storage of records (see findings in standard 37) and general communication within the home. Staff were heard discussing issues and passing on information relating to individual residents, and prospective residents in open areas, such as the nurse bases and communal areas. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.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 and 15 Residents are supported to participate in a range of social and recreational opportunities within the home but no recreational opportunities are made available to them to spend time outside the home and within the local community. Opportunities for residents to exercise choice in day to day living are often restricted due to limited availability of staff. Limited progress has been made to improve the provision of a varied menu and to ensure appropriate numbers of catering staff are on duty to meet residents dietary needs. The evening meal in this home is poor with little evidence that residents are offered either quality meals or choice. EVIDENCE: The majority of residents in the home choose to spend time in their own room and typically only use communal areas for social activities or mealtimes. The home has a designated activities coordinator who is employed at the home on a part time basis and provides a range of activities. Written records are kept for each resident which detail any social and recreational activities they have participated in. No specific budget is made available to the coordinator and as a result any resources are funded by ongoing fundraising such as raffles and coffee mornings. At the time of this visit the weather was exceptionally warm and sunny. A group of residents were observed sat in the courtyard area with the activities Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 13 coordinator and a carer. The staff were endeavouring to ensure residents were sat in the shade as much as was possible. There was one parasol available to them, which had recently been purchased from monies raised by fundraising. The parasol was not big enough to accommodate all of the 5 residents. An Immediate Requirement was issued in relation to this matter. Outings and excursions are reported to take place very infrequently due to lack of staff to assist and lack of appropriate transport. It was recommended to the home at the previous inspection that residents should be consulted to establish any preferences for day trips and if needs expressed, opportunities should be explored. There was no evidence consultation had taken place. Residents spoken to said that they would like the opportunity to go on trips out of the home. The home has an open visiting policy and visitors are welcome in the home at any reasonable time. Residents spoken to were asked if they felt they were able to make choices as part of day-to-day living. Responses included ‘not really’, ‘no, staff deal with downstairs first’ and another resident said that if there are not enough staff on duty they can not go to the dining room for lunch as they would wish and have to eat their meal in their room. Since the last inspection there has been further changes to the meals offered to residents. At the last inspection hot meals were made available to residents five evenings days a week. Menus seen show hot options only being available two or three evenings a week. At the time of this visit no hot meals were available during the evening due to unforeseen staffing shortages in the kitchen. Carers had to fulfil kitchen duties in the interim in addition to care duties. Residents spoken to were generally satisfied with meals received with the exception of the evening meal where comments were made about the fact that sandwiches were served every day. At the start of this visit (08.10hrs) the ground floor dining room was seen laid up ready for lunch for a total of nine places. Part full bottles of wine and sherry were observed on a table next to the dining table. In the rehabilitation unit a group of residents were observed sat at the table having breakfast, two carers were also in the room sat at away from the residents eating together. While both members of staff chatted together any interaction with the residents was minimal. The home’s lunchtime menu was seen which showed a choice of two main meals, with the exception of Sunday when a roast dinner is always served and a set pudding each day. The menu is written in a very basic manner and makes reference to the main part of the meal i.e.: chicken and ham pie, but does not details vegetables that will be served in addition. Residents are consulted over their choice of meal in advance, however discussion with some residents show that meals are changed and residents are not always advised of these changes and then do receive the menu choice they were expecting. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 14 A carer was observed consulting with a resident about their choice of meal, the resident was given two options for the main meal but it was clear they were not finding either option preferable. The carer was asked what would happen if a resident did not like either option and they replied saying that residents can have something else. The resident expressed surprise at this stating they were not aware other options might be available. The carer was not however able to say what the options might be as no list /menu for alternatives was available to them. Another resident spoken to, was also unaware that alternatives are available if neither choices for main meal are suitable. During the morning staff were seen taking residents to the dining table at 11.30 hrs ready for lunch, residents concerned had to wait some time as lunch was not due to be served until 12.30hrs Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 15 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 The home has a satisfactory complaints process in place, but evidence to demonstrate that residents and their representatives are fully aware of this process is limited. EVIDENCE: The home has a written complaints policy and procedure, copies of which are included as part of the home’s Statement of Purpose and Service User Guide. Not all copies had been updated with details of the Commission for Social Care Inspection. A record is reportedly kept of all complaints received and investigated by the home. Records were not however available for inspection at the time of this visit. The Commission for Social Care Inspection has received two complaints in relation to this home since the last inspection, and has also been advised by the home of two more complaints that have been received. Information received has demonstrated that each complaint was investigated appropriately in accordance with the home’s own policies and procedures During the course of this visit a relative of one resident approached the home manager and advised that they wished to make a complaint about the care their relative had received. The manager took time to listen to the issues raised by the complainant, but it was not evident from the discussions that the complainant was appropriately advised of the home’s complaints policy and procedures that were to be followed. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 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 standard(s) 19, 20, 22 and 26 The general standard of the environment within this home is satisfactory and provides residents with a comfortable and homely place to live in. Inconsistent practices in relation to infection control have the potential to put the health and well being of residents in this home at risk. EVIDENCE: The home is generally maintained to a good standard. Residents have access to communal space on both floors, which is homely in appearance. During this visit a partial tour of the home took place. One bedroom on the ground floor was noted to need attention to the plaster on the wall. Since the last inspection several bedroom carpets have been replaced and another carpet was being replaced during the course of this visit. A number of other carpets have been cleaned, however there still remains a number of carpets, which are heavily stained in appearance. The first floor kitchenette was seen, while it was noted to be cleaner that at the previous inspection, there continues to be a need for redecoration and upgrading. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 17 Prior to this inspection the home notified the Commission for Social Care Inspection (Worcester office) of problems with the nurse call system. On the day of this visit a member of staff reported a fault with the alarm in one bedroom. Engineers were on site and the fault was rectified during the visit. The laundry facilities were seen. The laundry is staffed 7 days a week. On the day of this visit one of the two driers was out or order and had been since 27th June 2005 (18 days). Before lunchtime three full baskets of wet washing were seen and were waiting to be dried. Staff expressed frustration with the situation and the impact of the delays on the service. Staff spoken to demonstrated an awareness of infection control measures necessary but were not totally up to date with information regarding the current status of the home with regard to infections. Several bars of soap were observed in a first floor communal bathroom. In addition to this care records for resident seen during this visit showed some inconsistent and inaccurate recording in relation to an infection and the care to be provided. Aids and equipment are made available to residents in accordance with their individual needs. It was reported that a hospital type bed has recently been ordered for the home. There is a need for storage arrangements for equipment to be reviewed. A first floor bathroom was being used to store walking aids on the day of this visit. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 18 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, 29 and 30. Poor staffing levels and poor staff deployment do not ensure care staff can meet the needs of resident residing on the nursing unit and are therefore placing them at risk. Ongoing failures in recruitment practices are not ensuring safeguards are in place to offer protection to residents living in the home. There has been no improvement in the quality of training records and there is now no assurance that all staff in this home have the necessary knowledge and skills to ensure the ongoing safety of residents . EVIDENCE: Staffing rotas are in place, which document the staff on duty 24 hours a day. On the day of this visit there were a total of 24 residents residing in the home , of which 20 were located in the nursing unit and 4 on the rehabilitation unit. On the day of this inspection, the home was staffed by the home manager, and 6 carers in the morning and a trained nurse and 5 carers in the afternoon /evening. 2 of these carers staff the rehabilitation unit at all times during the day/evening. Concerns were raised regarding staffing levels/ratios and deployment of staff. It was of particular concern that there were 2 carers to care for 4 residents on the rehabilitation unit and only 4 carers (and the home manager) to care for 20 residents on the two nursing floors. In addition to this there was evidence during this visit that the needs of residents in the nursing unit were not being appropriately met. • During the morning, an alarm call sounded from a first floor nursing room, a carer from the adjoining rehabilitation unit came and looked at Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 19 • • • display panel and went away. When challenged the carer said it was a call on the nursing unit and that they were working on the rehabilitation unit. When asked if they normally respond to calls, the carer said they would, but they suspected that the resident concerned probably just required assistance with washing. The carer was advised that the call may well be urgent and was asked to attend. Residents spoken to on the nursing unit referred to long delays in waiting for staff to assist them. One resident referred to a previous wait of an hour for assistance. One resident said that staff answer calls and enter their room telling them they will have to wait, and the staff cancels the call and leaves the room. The resident referred to anxieties created by this, as they are unsure if the carer will remember to come back and they are too afraid to ring again. When asked how frequent this happens the resident concerned responded ‘quite often’‘. Another resident spoke of delays and said ‘I have to wait too long, but it is not the staff’s fault’. A member of staff spoken to said staffing levels were satisfactory at the time of the inspection, but acknowledged that the home had a lower occupancy at the time. At the time of this visit due to unforeseen staffing shortfalls there were no catering staff to undertake evening kitchen duties (see findings in relation to standard 15) and care staff were having to fulfil this shortfall in addition to care duties. These arrangements were considered to be unsatisfactory . An Immediate Requirement was issued at the time of inspection in relation to staffing matters and the home required to submit an action plan to demonstrate how they will meet the requirement. A random selection of Staff records were seen. No improvements were noted since the home’s last inspection. It was noted that Criminal Record and POVA checks for 2 new members of staff had not been initiated until after they had commenced employment. The information regarding previous employment on the application form for one member of staff contradicted other documentation supplied by the applicant and the quality of the referees was questionable. This issue had not been taken up by the home. In addition to this the records for the second member of staff showed poor details of employment history and gaps in employment, which had not been explored prior to their appointment. A reference was not obtained until after the start date and there was no reason why a previous employer had not been approached. Staff training records were seen, which showed as per the previous inspection that some staff had not received essential training since their employment at Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 20 the home. The manager said training had been given but records had not been updated. Information was seen of in house training which is available to staff throughout the company for a range of topics such as : dementia , abuse , infection control and first aid. Each session runs for approximately an hour to an hour and a half. This is not considered to be sufficient time to evidence that staff have been appropriately trained in these high priority areas. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 21 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) 31,36, 37 and 38. The home has experienced a period of change and some significant effort is now necessary to promotes and safeguard the health, safety and welfare of residents living in the home. There is a need to maintain regular supervision of staff to provide opportunities to develop skills and strengths for the benefit of service users. EVIDENCE: The home is managed by Gillian Hall who is a registered nurse who has considerable experience and knowledge relating to the care of older people. Since the last inspection the home has experienced a number of changes to senior staff. This situation has put increased pressure on the manager in terms of time management. The manager reported during this visit that things were gradually improving, some staff had returned and she was now able to delegate some duties again. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 22 It was reported that staff supervision has been introduced but has not been implemented for all staff. At the commencement of this visit eleven bedroom doors were observed to be wedged/propped open and an immediate requirement notice was issued with regard to this. It was noted later during this visit maintenance staff were on site fitting ‘door guards’ to a number of doors. This action made some improvement to the situation but further action is necessary. Action is necessary to ensure all fire instruction/evacuation notices on display are complete. The kitchen was seen. Cleaning schedules are in place, but not all recordings were consistent. Temperature records relating to food stored and served to residents were incomplete with no entries recorded for 13 days in June 2005. Staff working in the kitchen were able to identify any potential risks to them, but there were no written assessments to support this information and no details of action to be taken to reduce or eliminate risks identified. This shortfall was also highlighted at the previous inspection. This visit has also highlighted the need to raise awareness in the home in relation to confidentiality in relation to the storage of records. Care documentation and medication administration records were not being stored securely and were readily accessible on nurse bases along with other key information. At many times throughout this visit both nurse bases were unattended. It was not possible during this visit to assess previous requirements in relation to standard 33 . Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 23 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 2 2 3 2 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 2 3 x 2 x x x 2 STAFFING Standard No Score 27 1 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 3 x x x x 2 2 1 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 24 YES 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 1,16 Regulation 4(1)(C ) Requirement The homes Statement of Purpose must detail: Up to date information of the number , relevant qualifications and experience of staff working in the home. Up to date information relating to the Commission for Social Care Inspection. (Previous requirement 22.1104 not met) The Service User Guide must include: Up to date information regarding terms and conditions in respect of accommodation to be provided. A copy of most recent inspection report . (Previous requirement 22.11.04 not met) All residents admitted to the home must receive an up to date statement of terms and conditions of occupancy which should include all matters detailed in National Minimum Standard 2.2. There must be suitably qualified, competent and experienced persons working in Timescale for action 1st September 2005 2. 1 5(1) 1st September 2005 3. 2 5 1st September 2005 4. 4, 14, 15, 27 18 Immediate and ongoing Page 25 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 5. 7, 8 12(1) 15(1) 6. 7,8 12(1) 15(1) 15(1) 7. 7, 8, 37 8. 8,37 12(1) 9. 7 15(1) 10. 9, 37 13(2) 11. 12. 9 10 13(4) 12(4) the care home at all times, in such numbers as are appropriate for the health and welfare of residents. (Previous requirement 27.05.04 and 22.11.04 not met) Each resident must have care plans in place, which accurately reflect their current physical needs and contains accuarte details of the care and support to be provided by staff to meet those needs. A care plan must be initiated whenever care needs are identified. (Previous requirement 22.11.04 not met) Individual records must be kept in relation to any wounds , which includes details of regular assessments, current treatment and reviews. Accurate written records must be kept of fluid intake and output for all residents identified to require monitoring of fluid balance. Care plans must be put in place for all residents with identified emotional, social and psychological needs. Plans must demonstrate how these needs are to be supported by staff. (Previous requirement 22.11.04 not met) Any written additions or amendments to the medication administration records must be dated, checked, and signed by two staff. A risk assessment must be completed for residents who are prescribed Warfarin. All staff in the home must work in accordance with the homes policies with regard to the privacy of residents at all times. (Previous requirement 22.11.04 not met) Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing. Immediate and ongoing Immediate and ongoing Immediate and ongoing. Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 26 13. 10 12(4) 14. 15. 12, 38 12 13 16 16. 15, 27 18 17. 15 12(2) 18. 15,37 17(2) Schedule 4 17(2) Schedule 4 23 19. 16, 37 20. 19 21. 19, 26 23 22. 23. 19 19, 26 23 23 All staff must ensure that any information relating to residents is handled in a manner that complies with the homes policies on confidentiality Equipment must be provided to protect residents from the sun when sitting in the grounds. Arrangements must be made where needs identified to enable residents to engage in local, social and community activities . Catering staff must be employed to fulfill catering duties and to ensure residents dietary needs are met. Care staff levels must not be compromised to fulfil these duties. An up to date record of the days menu must be on display in the home which includes all relevant menu options available to residents. (Previous requirement 22.11.04 not met) Written records must be kept in the home of all meals served to residents each day including any alternative options. (Previous requirement 22.11.04 not met) Written records must be kept in the home of all complaints received by the home,any investigation undertaken and any subsequent action. Remedial work must be carried out to the plasterwork in one ground floor bedroom as identified during the inspection Any soiled or stained carpets must be cleaned or replaced as necessary. (Previous requirement 22.11.04 met in part only) The area by the sink in the first floor kitchenette should be redecorated. The broken tumble drier must be repaired or replaced. Immediate and ongoing Within 24 hours Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing 1st October 2005 1st October 2005 1st October 2005 Immediate Page 27 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 24. 22 23 25. 26, 38 13(3) 26. 29, 37 19 27. 29 19 28. 29, 37 19 29. 30, 37 18(1), 13(4) 30. 30, 37 18(1) 31. 30 18(1) Appropriate storage must be availabe for equipment which avoids the sue of communal areas and bathrooms . All staff must adhere to the homes policies and procedures in relation to infection control measures, and appropriate information must be passed on to all staff as necessary to ensure controls are maintained. Two satisfactory written references must be obtained prior to the commencement of emeployment of any new staff. (Previous requirements 27.05.04 and 22.11.04 not met ) Any gaps in employment history must be explored as part of the selection process for any prospective staff. (Previous requirement 22.11.04 not met ) POVA checks and Criminal Record Bureau checks must be obtained prior to any new staff commencing employment in the home . Induction records must be signed and dated by the relevant trainer , to demonstrate satisfactory completion of any training . (Requirement from previous inspection 22.11.04 not inspected) Each member of staff must have a training and develpment assessment and profile , which accurately details all training undertaken to date. (Previous requirement 22.11.04 not met ) Collate and review all records relating to training undertaken to date. The purpose of this is to establish training carried out to adte and identify training needs fro the future. (Previous requirement 22.11.04 not met ) 1st October 2005 Immedate and ongoing Immediate and ongoing Immediate and ongoing Immediate and ongoing Immediate 1st Septmber 2005 1st September 2005 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 28 32. 33 24(1) 33. 36 18 34. 35. 37 38 17 23(4)(c ) 36. 38 13, 16 37. 38 16 38. 38 23 Implement a programme of quality assurance that enables staff,service users and their representatives to directly influence the service provided. (This standard was not inspected) All care staff must formal supervision at least six times a year. Written records must be kept of all supervision that takes place . All personal information relating to residents must be stored securely. Fire doors must never be held open by means which have not been appproved by the fire officer. If a fire door needs to be held open for health and safety reasons, a solution must be provided which is approved by all relevant authorities.(Previous requirements 27.05.04 and 22.11.04 not yet met in full ) Risk assesssments must be documented for the kitchen and appropriate action taken to ensure any risks to staff accessing these areas are eliminated. (Previous requirement 27.05.04 and 22.11.04 not met ) Accurate written records must be kept of all food temperatures and cleaning schedules adhered to . Fire evacuation/information notices displayed in the home must accurately detail the action to be taken in the veent a fire alaram sounds. 1st September 2005 1st October 2005 Immediate and ongoing Immediate 1st September 2005 Immediate and ongoing Immediate and ongoing Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 29 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 7 12 Good Practice Recommendations Look at opportunities to encourage more involvement from residents in their individual care planning. Consultation should take place with residents to establish any preferences for outings and excursions . In the event preferences are identified, opportunities should be made available and appropriate supervision provided. (Previous recommendation 22.11.04) Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 30 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Westley Court Nursing Home E52 S4154 Westley Court V236971 140705.doc Version 1.40 Page 31 - 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. 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