Inspection on 27/02/06 for Westmeade

This inspection was carried out on 27th 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westmeade 11/10/07

Westmeade 27/10/06

Westmeade 29/09/05

Westmeade 18/01/05

Westmeade 03/06/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Westmeade 69 Westmeade Close Cheshunt Hertfordshire EN7 6JP Lead Inspector Patricia Rogan Unannounced Inspection 27th February 2006 15:00 Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 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 Westmeade DS0000019616.V285596.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westmeade Address 69 Westmeade Close Cheshunt Hertfordshire EN7 6JP 01992 629963 01992 629963 FP 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 P Lopez Dr S Collen Janet Ann Fishenden Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 3 people mental disorder (only when asociated with a learning disability) 29th September 2005 Date of last inspection Brief Description of the Service: Westmeade is a three bedroomed semi-detached house and is located in a quiet close on a modern residential estate in Cheshunt. It is close to the town centre with its shops, leisure facilities, railway station, bus service and other amenities. The home provides accommodation for three women with learning disabilities and associated mental health support needs. The house is domestic in design, style and décor, with a small office on the first floor. There is a pleasant garden to the rear. The service offered is specialised and individually tailored to meet the complex needs of the individual service users. The home is staffed twenty four hours a day. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive unannounced inspection and took place during the late afternoon and early evening of one day. A brief tour was made of the premises and residents and staff were present during the inspection. Some records and care plans were inspected with the manager. Where core standards were inspected during the previous inspection of 29th September 2005, these were not all inspected on this occasion. Please see the report of the previous inspection for details. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments should be more detailed to set out how the identified risk is to be addressed. Staff meetings and handovers should be recorded accurately to demonstrate that individual service users’ care plans have been discussed with the staff and that staff sign that they have read and understood the minutes. If the identified care needs cannot be met, the reason for this must be recorded by the member of the care team and discussed with the manager or person in charge at the time. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 6 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. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users’ care plans reflect the service user’s needs and wishes. EVIDENCE: The care plans identify what the service user is able to do and what the service user would like to do. Ways of meeting these needs are discussed with the service user, the staff and others involved in the care and support of the service user. A daily and weekly programme is developed and reviewed on a regular basis. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 The service user’s individual care plans reflect their care needs and their social and personal development. Risk assessments are in the individual care plans although these should have more detail on what action should be taken should an emergency occur. EVIDENCE: The care plans and weekly activity programmes are individualised and regularly reviewed to ensure that the service user is given varying opportunities to benefit from educational and social experiences in addition to life within the home. Risk assessments should have more detail to identify the action to be taken should an emergency occur and this information relayed to all members of staff. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The service users are supported to take part in activities appropriate to their age and wishes. EVIDENCE: Each service user is given the opportunity to attend social activities such as college, sports activities, meeting with family and friends and visiting local events in the town. This is done by consultation with the service user and those who are involved with the service user, such as family and professionals. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users are regularly involved in discussion about their personal care needs and ways these will be met. EVIDENCE: Service user’s care needs identify each aspect of personal care needs and what the service user’s wishes are. This is relayed to the care staff and reviewed if needs change. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Policies and procedures are in place to ensure the safety of the service users. Staff training in the protection of vulnerable adults is on-going . EVIDENCE: There are clear guidelines for monitoring the care and support which is offered to service users. The vetting procedure of new staff prior to appointment is strictly adhered to. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the last inspection on 29th September 2005. Please see the report of that inspection for details. EVIDENCE: Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 36 There is an established staff team and service users know them well which means service users understand the roles and responsibilities of the staff. Staff have ongoing training and the manager said she is committed to ensuring that staff skills are kept up to date. Supervision records show that staff have the required regular supervision, however, more detail is required. EVIDENCE: Discussion with a resident showed that she was aware of the team structure and was able to say what staff assisted her with and what the role of the manager was. Staff have access to ongoing training and some have completed the NVQ. Recently appointed members of staff had various training in their previous care setting and this means there is a varied skill mix to benefit the service users and the team. Supervision should identify future training needs and individual skills when working with residents to ensure resident’s goals and care needs are being met. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. There are regular resident meetings and the minutes show that residents are asked for their views. There are health and safety audits in the home and there are individual risk assessments which are regularly updated. Activities inside and outside the home are also monitored to ensure the well being and safety of the residents. EVIDENCE: Discussion with the resident and the staff showed that in addition to the regular resident meetings, residents are involved on a daily basis in discussion about events in and out of the home. Health and safety checks are made in the home and risk assessments are reviewed as care needs change. Staff supervision records must show that this subject has been discussed. Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X X X 3 X X 3 X Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 17 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(4) Requirement The action taken to minimise identified risks and hazards should be discussed with the service user and must be written in detail in the service user’s care plan. One-to-one and group supervision sessions and observation of practice must contain more detail to demonstrate that the outcomes for service users and staff have been discussed. Timescale for action 30/04/06 2 YA36 12(5) 30/04/06 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 Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Westmeade DS0000019616.V285596.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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