Inspection on 21/11/06 for Westmead

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Westmead 05/08/09

Westmead 15/08/07

Westmead 20/12/05

Westmead 02/08/05

Westmead 24/03/05

Westmead 02/09/04

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 Westmead Westmead Close Off Ledwych Road Droitwich Spa Worcestershire WR9 9LG Lead Inspector Y South Unannounced Inspection 21st November 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmead Address Westmead Close Off Ledwych Road Droitwich Spa Worcestershire WR9 9LG 01905 778353 01905 776376 westmead@heart-of-england.co.uk www.heart-of-england.co.uk Heart of England Housing and Care Limited 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) Mrs Sueanna Elizabeth Stokes Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (35), Physical disability over 65 years of age (35) Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service user category LD (E) is in respect of a named person only. Date of last inspection 20/12/05 Brief Description of the Service: Westmead is a purpose built home offering a residential care service to a maximum of 35 people of either sex, over the age of 65 years. Two places are reserved for people who require respite care only. The home offers permanent residential care to older people who have care needs associated with physical disabilities and/or dementia illnesses. Care is also offered to one named older person with learning disabilities. The home provides a safe, homely environment for people who are no longer able to cope in the community, and enables them to lead a full and active life within a risk management framework. There are 33 single bedrooms and 2 double rooms in the two-storey building, and a range of communal lounges, a dining room and a spacious, level, and accessible garden. A shaft lift facilitates movement between floors. Handrails are appropriately placed within the home and in the gardens. Special equipment is provided for example to assist with bathing, mobility and lifting. The home is situated in a small housing estate on the outskirts of Droitwich Spa and public transport facilities are within reach. Heart of England Housing and Care Ltd own the home and the registered manager is Mrs Sueanna Stokes. The pre inspection questionnaire, completed by the registered manager and submitted to the Commission for Social Care Inspection (Commission for Social Care Inspection) on 11.10.06 stated that the fees were £1460 per month. Additional charges were made for private purchases of hairdressing services, chiropody, newspapers and magazines, opticians and dry cleaning. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social Care Inspection since the last inspection that took place on 20.12.05 and the information obtained during fieldwork on 21.11.06. The fieldwork took place over six and a quarter hours during which the inspector spoke to seven residents, five staff and the registered manager. Documents were assessed and a partial tour of the premises was also undertaken. A phone call was also made to a relative seeking their opinion of the service provided. Prior to the fieldwork the home was asked by the Commission for Social Care Inspection to distribute questionnaires to the residents, relatives and health care professionals. No responses were received from residents, two from relatives and one from a health care professional. The focus of this inspection was on the key National Minimum Standards and the requirements that arose out of the previous inspection. The inspector was assisted in the fieldwork by the registered manager the hotel services manager and a senior lead carer. Equality and diversity is actively respected in documentation The manager stated that one resident came to England from South Africa many years ago. Some residents were visually impaired. The registered provider was able to convert the inspection report into large print or an audiotape for those who needed this. All residents understood spoken and written English as did all staff. What the service does well: The home provides a warm and friendly welcome and a homely atmosphere. The variety of small lounges provides facilities for quiet or companionship depending on the individual’s choice. The pleasant dining room enables an immediate link to the catering staff and the menu choice for the day is displayed. Everywhere is clean, tidy, well decorated and maintained. Residents describe the staff as ‘excellent’, ‘lovely’, ‘helpful’. They are well recruited and there is a strong commitment to training through the team. A wide range of in-house and community activities are made available from which residents can choose to participate if they wish. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 6 Residents describe the choice of meals as ‘great’ ‘could not be bettered’. 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. The summary of this inspection report can be made available in other formats on request. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (An intermediate service is not provided. Therefore standard 6 has not been assessed.) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives are provided with the information and support they need to assist them in make a decision regarding admission to the home. An assessment of needs is undertaken so that the home only offers a service to people whose needs the home can meet. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 9 EVIDENCE: Copies of the Statement of Purpose, the Service Users’ Guide and previous inspection reports were displayed in the entrance to the home. The manager stated that information was tailor made to the needs of the person making inquiries. A ‘Carers Check list was provided, a brochure, and a copy of the Heart of England News Letter. A relative confirmed that they had received copies of all the documents and all their questions had been answered. They had been impressed by their welcome, the environment and the positive ethos of the home. The compliment records in the home provided evidence that prospective residents and their supporters were given all the information and assistance that they wanted. Prospective residents were able to come for a ‘taster’ visit and/or a trial stay. The care records of three residents were assessed. A full assessment of needs had been undertaken and an initial care plan had been drawn up. In addition identified risks were assessed and supported by relevant care plans to manage the risks. The records of ‘Life Histories and Family Involvement’ were particularly informative. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive the individual personal and health care they need. Medication is administered safely according to prescription. Privacy and dignity is respected and End of Life wishes are complied with. EVIDENCE: The three care records assessed contained detailed information to guide staff in the delivery of care. Care plans were well drawn and regularly reviewed and updated. The reviews were conducted by the key worker and relevant resident. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 11 It was suggested that the resident’s involvement could have been better evidenced. However a relative confirmed that she had been invited to contribute to a review and had been given every opportunity to speak on behalf of her relative. The manager and senior lead carer continually monitored the quality of recording and the content of the documents. Daily records indicated that the residents were well supported by the health care professionals. Visits were undertaken by GPs, District Nurses, Community Psychiatric Nurses, Continence Advisers as well as chiropodists and opticians. Hospital appointments were also kept. A relative confirmed that very soon after admission her relative had been visited by their ‘new GP and health and medication had been reviewed. Medication was well managed. Storage and recording was acceptable and staff had received appropriate training. Training had been undertaken by Boots and it was planned that in the New Year additional training would be provided by the Worcester College of Technology. Privacy and dignity was respected. This was confirmed in conversation with the staff and the residents. All bedroom doors were fitted with approved locks and residents could have their door key and the key to their lockable storage if they wished. Private telephone calls could be made and received. Mail was delivered unopened or held for relatives according to the agreement made with the residents. The three records assessed all contained information describing the residents’ End of life Wishes. A member of staff described the palliative care provided by the home as second to none. This was supported by the many thank you cards and letters in the compliments file, received from relatives. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff support residents so that they can lead the life routines they wish and choose to participate in a range of in-house and community activities. Opportunities and support is provided so that links are maintained with families and friends. Daily choices of good quality meals are provided so that residents can select and enjoy their food. EVIDENCE: It was observed that residents were able to use the lounges of their choice or stay in their rooms if they wished. One resident said that she liked to be quiet while others told the inspector they liked to be with their friends. Everyone was able to move around the communal areas of the home as they wished. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 13 The manager confirmed that although the majority liked the dining room some people preferred to dine in their rooms. The menu choice was displayed daily in the dining room. The quarterly analyses of compliments that had been received by the home demonstrated that 84 relating to catering had been received by the home since January this year. It was stated in the pre inspection questionnaire that a range of in-house and community activities were arranged for the residents. An activities organiser was employed for 12 hours a week and the manager said that in addition care staff undertook an activity every two weeks. This used their individual skills and enlarged the choice further. The notice boards around the home advertised the programme and forthcoming events. The records assessed indicated that the residents were of the ‘Christian’, ‘Methodist’ and ‘Church of England’ faiths. More information needed to be included as to what support, if any, the individuals needed and wanted. A resident said that she enjoyed taking Holy Communion when the vicar came. There were also strong links with the Salvation Army in the home and the community. The minutes of the residents’ meetings and the questionnaires they completed each year demonstrated that they were kept informed of events and plans for the home and were able to express their opinions and make suggestions. The home participated in the Worcestershire ‘Having your Say’ group and the home had a residents’ representative who provided another link between residents and staff. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have access to copies of the complaints procedure so that they are able to raise any concerns they have with confidence that they will be listened to and responded to appropriately. Suitable staff are recruited and trained so that vulnerable people are not put at risk. EVIDENCE: Copies of the complaints procedure were in the Statement of Purpose and the Service Users’ Guide. The questionnaire responses that were returned to the Commission for Social Care Inspection indicated that the relatives knew how to raise their concerns and neither they nor the doctor had had reason to make a complaint. The Commission for Social Care Inspection had received no complaints, concerns or allegations concerning the home since the last inspection. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 15 A relative said that she had received an immediate response to her concerns and had been thanked for drawing them to the attention of the manager so that they could be addressed. The pre inspection questionnaire indicated that the home had received two complaints in the past twelve months and both were substantiated. The record in the home was assessed for the period from the last inspection. There was one complaint concerning the clothing of a resident. It had been investigated and addressed. The staff who were interviewed confirmed that they had been recruited through a sound procedure. Assessment of their records supported this. References and checks had been obtained and training had included the Protection of Vulnerable adults. The pre inspection questionnaire and records confirmed that the home responded appropriately to concerns relating to adult protection and where necessary advocacy services had been used. Communication with all involved had been of a high standard. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents live in pleasant accommodation, which suits their needs. Systems and equipment reduce the risks of cross infection as far as possible. EVIDENCE: The pre inspection questionnaire indicated that that decoration and refurbishment of the home had continued. New carpets had been laid in some bedrooms, lounges and the dining room. A medic bath had been removed and the room converted to a shower room. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 17 It was observed that the décor was of a high standard. Residents were able to use any of the attractively decorated lounges or stay in their bedrooms if they wished. The bedrooms were well furnished and personalised with photographs, pictures and ornaments. The new shower room was attractive and practical. It had proved successful and popular with residents and staff. The garden was level and well laid out. A sensory garden was included and the garden paths were railed to assist residents. It was observed that the risks of cross infection were managed by the availability and use of liquid soap, disposable towels and personal protective equipment. The laundry was clean, tidy and well organised. The laundry machines met infection control requirements and staff had received training in infection control. A relative said that they had been impressed by the clean, light, airy, welcoming feel of the home. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are sufficient well-recruited and trained staff to meet the current needs of the residents. EVIDENCE: The pre inspection questionnaire indicated that twenty care staff were employed. Eleven staff had left the home since the last inspection for a variety of reasons. Recruitment had taken place and currently there was only a vacancy for a night care assistant. Documentation indicated that the recruitment process was based on equal opportunities and an equality and diversity audit was undertaken every three months. Three staff came from other countries. All spoke good English. Two of the three also had a good standard of written English. A paper free National Vocational Qualification (NVQ) course was being sought for the third person. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 19 The duty roster, confirmed by the manager and staff, indicated that four care staff, a lead carer and a manager were on duty during the waking day. At night the home was staffed by two waking staff and one person sleeping in. In addition and manager was on call. Staff confirmed that these staffing levels enabled them to meet the current needs of the residents. Staff and documentation demonstrated a commitment to training. Since the pre inspection questionnaire had been submitted the care staff team had increased to twenty-one people and fifteen of them had done, or were doing, NVQ courses. This equates to 71 . Well above the National Minimum requirement of 50 . The pre inspection questionnaire and staff and records indicated that in addition to mandatory courses, training had also been undertaken in dementia care, palliative care, and medication training. The manager said that training had also been booked to take place in the New Year concerning dementia and sexuality. Discussion with staff demonstrated that they were confident and competent in their roles and understanding. They were observed carrying out their duties with skill and sensitivity. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The strong stable management team ensures that the home is managed in the best interests of the residents and the attention to health and safety is in the best interests of everyone. EVIDENCE: The home has a stable management team and is well supported by the organisation. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 21 The registered manager has been in post for some time and is qualified and experienced in her role. The staff described her as ‘good’, ‘approachable’, ‘sorts out problems’. The questionnaire responses were positive regarding the communication and quality of the home. Staff confirmed that they received supervision and felt well supported by the management team. The home distributed questionnaires to residents every year. These sought their opinions regarding the standard of care, catering and accommodation. In addition questionnaires were made available to relatives and professionals and their views were welcome. The documents demonstrated that the responses were read and action was taken to improve the service and respond where necessary. In addition to the questionnaires a range of systems were regularly audited. Some of these were the comment and complaints, accidents, equality and diversity. The National Minimum Standard for Quality Assurance was broken down to demonstrate where evidence of compliance was found. These elements of a quality assurance system identified were weaknesses could be improved and the service could be developed further. Many residents had money held in safekeeping and managed on their behalf by the home. There was secure storage and good documentation. Health and safety was well addressed. The pre inspection questionnaire indicated that systems and equipment were regularly checked and the maintenance file indicated that there was an ongoing programme of care. A maintenance book was available in which staff were able to enter their concerns, which in turn were actioned. The Fire Risk Assessment for the home was drawn up in October 2004 and was reviewed in November 2006. All fire safety checks were being carried out at the required frequency and staff were receiving training and participating in fire drills. Staff were also receiving training in other health and safety matters and this was endorsed by their documentation. Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 22 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Westmead DS0000018696.V313895.R01.S.doc Version 5.2 Page 25 - 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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