Inspection on 22/01/07 for Westmoor View Nursing Home

This inspection was carried out on 22nd January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westmoor View Nursing Home 09/02/09

Westmoor View Nursing Home 07/12/07

Westmoor View Nursing Home 19/10/05

Westmoor View Nursing Home 12/05/05

Westmoor View Nursing Home 16/11/04

Westmoor View Nursing Home 19/04/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westmoor View Nursing Home Dixon`s Bank Marton Middlesbrough TS7 8PA Lead Inspector Derek Stow Key Unannounced Inspection 22nd January 2007 11:15 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 Westmoor View Nursing Home DS0000000223.V326226.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. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westmoor View Nursing Home Address Dixon`s Bank Marton Middlesbrough TS7 8PA 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) 01642 316737 01642 324685 pocklinc@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Caroline Henriette Elizabeth Pocklington Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That a maximum number of 5 places may be used at any one time for accommodation of persons who are 55 years and over with a physical disability. To admit two named individual who are under 55 years of age in the category of Physical Disability 19th October 2005 Date of last inspection Brief Description of the Service: Westmoor View is set within terraced grounds, located off Dixons Bank in the residential area of Marton. The home is located approximately five miles from the centre of Middlesbrough. The home is close to a nearby shopping centre and other local amenities and is served well by local transport. The original house was built in the 1860s yet the home still retains many of its original features including a number of wood panelled rooms, original fireplaces and large bay window. A choice of furnished lounges is available where service users can find a quiet place to sit and read or entertain guests. There are thirty-five private bedrooms for residents, five of which are large enough to be used as double rooms to accommodate couples if requested. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Westmoor View was unannounced and took two visits to the Home totalling seven and quarter hours. The inspection included a tour of the building, examination of various records and time spent talking with four residents, two relatives, three staff and the Manager. The inspection also took account of information gathered about the service over the year including a pre-inspection questionnaire completed by the manager as well as surveys of resident and relatives’ views. This inspection looked at those standards, which the Commission for Social Care Inspection regard as Key minimum standards. The details of any issues identified as requiring action together with recommendations for improvement are to be found at the back of this report. What the service does well: What has improved since the last inspection? What they could do better: The Manager must meet the requirements detailed at the back of this report regarding the giving of medication and the maintenance in one bathroom. The recommendations made should be considered as suggested improvements to the service delivered. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Westmoor View Nursing Home DS0000000223.V326226.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 Westmoor View Nursing Home DS0000000223.V326226.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): Standards 1 and 3. Quality in this outcome area is (good). People making enquiries about staying short term or living at Westmoor View have the information they need to help them make an informed choice about where to live. Residents needs are assessed before moving in to Westmoor View. Intermediate Care is not provided at Westmoor View. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An information pack about to Westmoor View was examined. This contained valuable information including a checklist of questions to help people to choose a Care Home, information about paying for care and financial support from Local Authorities and Primary Care Trusts as well as a brochure, menus and fee levels at Westmoor View itself. Nine out of ten surveys returned from residents stated that they had sufficient information to help them in making a choice of Care Home. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 9 Three residents files were examined and these held good evidence of pre-admission assessment information being gathered. The Manager said that she visits people either at home or in hospital as part of the assessment process before a decision is made to admit a person to Westmoor View. Westmoor View Nursing Home DS0000000223.V326226.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): Standards 7, 8, 9 and 10. Quality in this outcome area is (good). All residents have a plan of care which sets out their personal, social and health needs. Registered nurses are on duty at all times to ensure nursing needs are met and appropriate policies and procedures are in place for the giving of medication. Residents at Westmoor View feel that they are treated with respect and they enjoy the privacy of their rooms as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents files were looked at in detail and these all had good evidence of personal, health, social/activities assessment and care planning as well as relevant risk assessments and nutritional assessments. There was evidence that residents/relatives are involved in care planning and monthly reviews by key workers take place although the record of this should be strengthened to ensure that specific dates are always recorded. Appropriate policies and procedures are in place for the receipt, storage and giving of medication as well as any medications unused and returned to the pharmacy. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 11 A check on controlled drugs was found to be correct, however one dosage of antibiotics did not tally with the record of tablets given. The manager must ensure that all medication is given and recorded correctly. In discussion with the Manager it is recommended that in order to strengthen the audit trail for all non-monitored dosage medicines that a clear start date is recorded on all tablets and bottles. All residents have a lockable cabinet in their rooms for the safe keeping of personal items as well as medication should they wish to manage their own and have been assessed as being able to do so safely. One resident currently manages her own inhalers. Of the seventeen resident/relative surveys returned to the Commission For Social Care Inspection the majority were satisfied with the personal and health care given at Westmoor View and on the day of inspection all four residents spoken with as well as two relatives said they were satisfied. One resident said “ I can go out or go to bed whenever I like. Another said, “ the nursing and care staff are very attentive”. Westmoor View Nursing Home DS0000000223.V326226.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): Standards 12, 13, 14 and 15. Quality in this outcome area is (good). Residents find life at Westmoor View satisfactory. There are regular activities organised during the week, a variety of trips out across the year and there is open visiting for friends and relatives. Residents have choice and control over their lives. A varied and balanced diet is provided in pleasant dining areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager said that a “Life Biography” is developed for each new resident, which helps to personalise individual, plans of care. A client profile is also developed called “ A day in the life of----“ which describes a person’s daily routine and likes and dislikes. In addition the Activity Organiser who was spoken with said that she sits down with each resident to develop an individual social/activity plan to help ensure that a persons interests and hobbies can be maintained. This is excellent practice. Records were seen as evidence of this and residents spoken with confirmed that their interests and small group social outings are catered for. It is recommended that where a resident declines to engage in such an activity plan then this should be recorded. One resident said that a carer takes him to a centre in Middlesbrough and to the pub if he wants to. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 13 Another resident said that he gets a bath or shower whenever he likes, keeps a bottle of whiskey in his own room and goes out whenever he likes. Residents were observed to be using their own private rooms as they wished. The manager said that religious needs are met with the local Methodist And church of England Ministers visiting regularly; with Roman Catholic and other clergy visiting individuals as required. Appropriate menus providing variety and choice were in place, which rotates every four weeks and residents, spoken with were very satisfied with the quality of food provided. The manager said that the BUPA chefs are now given targets covering quality and variety as well as giving attention to salt, sugar, fruit and vegetables. Westmoor View Nursing Home DS0000000223.V326226.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): Standards 16 and 18. Quality in this outcome area is (good). Residents and relatives are confident that their views and concerns are listened to and acted upon by staff and managers and that residents are protected at Westmoor View. Staff are trained in protecting residents from abuse and training is on-going for new staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were no complaints reported to the Commission For Social care Inspection over the past year. Two complaints had been received internally since the last inspection one regarding laundry and one regarding food. The records were examined and is was felt that these had been responded to, investigated and resolved appropriately. Residents and relatives spoken with during the inspection said that they were confident that the Manager and staff listen to and respond positively to any concerns that they may have. The policy and procedure should now be updated to make it clear to residents and relatives that the responsibility to receive, resolve and investigate complaints is with the management of the Home and those agencies such as Social Services and Primary Care who contract or commission services on behalf of individual residents. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 15 The Commission for Social Care Inspection is primarily a regulator of services and not a complaints investigation body. However residents, relatives and members of the public can still report any concerns about the running of a particular service to the Commission who will consider the issues and whether the service is meeting the required standards and regulations. The protection of vulnerable adults policy and procedure is in place and Staff spoken with during the inspection all knew what to do if they suspected abuse of residents and had undertaken training. Westmoor View Nursing Home DS0000000223.V326226.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): Standards 19 and 26. Quality in this outcome area is (good). Westmoor View is generally well maintained, safe, comfortably furnished and well decorated although one bathroom upstairs requires some maintenance. The Home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home took place, which confirmed that all the bedrooms examined were clean, well furnished, decorated and personalised with residents’ own possessions. All the residents spoken with were very happy with their own bedrooms and no unpleasant odours were apparent. Westmoor View has a fulltime maintenance man and a full range of records was in place. In discussion with the Manager it was agreed that some ongoing maintenance is required to the tiles and flooring in an upstairs bathroom where some damage has occurred due to contact with the metal hoist. This must be done within the next three months. The Home was seen to be clean and hygienic throughout. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is (good). Residents at Westmoor View are supported by sufficient numbers of properly recruited, qualified and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rotas showed that there was sufficient Nursing and Care staff on duty to meet the needs of the residents. Apart from the Qualified Nurses Westmoor View now exceeds the minimum standard for qualified care staff and has 55 of Care staff trained to NVQ level 2 or above. The manager said that four staff are about to start working towards NVQ level 3. Staff files examined showed evidence of robust recruitment including relevant identity checks, Criminal Record Bureau checks as well as two references. Three staff were spoken with all of whom said that they had good access to training, had all undertaken training in the protection of vulnerable adults and training records examined confirmed this. The manager said that each member of staff has a training record and there is a training matrix to help ensure that all statutory training is kept up to date. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is (good). The residents of Westmoor View benefit from a service which is well managed and run in their best interests. Quality monitoring systems are in place and the residents finances, health, safety and welfare is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager of Westmoor View is an experienced and qualified Nurse and additionally holds the Registered Managers award. There are several quality assurance systems in place which focus on the needs of the residents including care planning, review, monthly resident meetings, regulation 26 visits by a different manager, a range of internal audits including a monthly managers audit as well as an annual survey of residents, the results of which are made available within the Home. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 19 Appropriate systems and records are in place to safeguard any monies kept on behalf of residents. A number of health and safety records were examined to confirm that up to date maintenance/checks and records were in place. Checks made on hot water temperatures were satisfactory, an up to date gas safety certificate was in place as well as a recent fire risk assessment. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 20 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 4 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP19 Regulation 13(2) 13(4a) Requirement The manager must ensure that all prescribed medicines are given and recorded correctly. The maintenance to the tiles and flooring of an upstairs bathroom must be carried out. Timescale for action 22/01/07 31/03/07 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 OP9 OP16 Good Practice Recommendations It is recommended that the manager develop a clear audit trail for all non-monitored dosage medicines. Update all Complaints information as advised. Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Westmoor View Nursing Home DS0000000223.V326226.R01.S.doc Version 5.2 Page 23 - 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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