Inspection on 07/12/07 for Westmoor View Nursing Home

This inspection was carried out on 7th December 2007.

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

Westmoor View Nursing Home 09/02/09

Westmoor View Nursing Home 22/01/07

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 Val Daly Unannounced Inspection 7th December 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westmoor View Nursing Home DS0000000223.V356483.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.V356483.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), Physical disability (10) of places Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 40 2. Physical disability - Code PD, maximum number of places: 10 The maximum number of service users who can be accommodated is: 40 22nd January 2007 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. Weekly fees are from £370 to £700 Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed in one inspection day, by an Inspector and an Expert by Experience. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including resident’s assessments and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. Nine residents and four relatives were engaged in discussion with the expert by experience about living at Westmoor View. The inspector spoke with three members of staff and the manager. The expert by experience commented that she felt the residents were; well cared for, respected, able to get out of bed when they wished, able to have a bath when they wished, relatives and friends could visit at any time, able to make phone calls, felt they were able to make telephone calls, felt they were able to discuss problems or concerns with staff, felt supported with staff, can follow their respective religions, go out with relatives or a member of staff to nearby shops, were able personal belongings, and if desired, chose own curtains and bedding to furnish their bedrooms, were happy with the quality and choice of food. The manager had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the Registered Person’s own self-assessment of the service and care that is provided. The information was detailed and comprehensive. The Commission for Social Care Inspection sent ten questionnaires to the home for residents and relatives to complete. Seven were returned. Comments received can be read within the report. This was a positive inspection, in which the Inspector and Expert by Experience was warmly welcomed by all. Feedback both from the inspector and the expert by experience was well received and there was constructive discussion throughout. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the previous inspection new assessment and care planning documentation had been put in place and each resident’s needs had been re assessed. The documentation is person centred and the areas covered are; communication, lifestyle, maintaining a safe environment, mental state and cognition, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, sleeping, pain, medication, end of life arrangements, any personal needs and expectations or medical conditions, activities including comments from the resident and showed evidence of resident/relative involvement. A map of the resident’s life is included, showing their younger life, where they lived, employment, children, hobbies and interests. Several bedrooms have been refurbished and some profiling beds have been purchased. A new carpet was in place in one of the lounge areas, along with some new curtain chairs. A new maxi hoist, which also weighs residents, had also been purchased. Changes had also been made outside the home, raised flowerbeds to enable residents to participate with the gardening were in place, along with an ‘Arbour’. The patio area had been extended for ease of access for wheelchairs. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 7 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. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 8 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.V356483.R01.S.doc Version 5.2 Page 9 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&6 People who use the service experience excellent quality outcomes in this area. People who use the service have their needs assessed. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Each resident has his or her needs assessed by a care manager prior to moving into the home. The manager also carries out her own assessment meeting the prospective resident in either their own home or in hospital. Four resident’s files were examined. Since the previous inspection new assessment and care planning documentation had been put in place and each resident’s needs had been re assessed. The documentation is person centred and the areas covered are; communication, lifestyle, maintaining a safe environment, mental state and cognition, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, sleeping, pain, medication, end of life arrangements, any personal needs and expectations or medical conditions, activities including comments from the Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 10 resident and showed evidence of resident/relative involvement. A map of the resident’s life is included, showing their younger life, where they lived, employment, children, hobbies and interests. The home does not provide intermediate care. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Four resident’s files were examined and they each contained an individual care plan following on from the assessment. Personal and social care needs were included in the plans along with a ’map of the resident’s life’. The plans were reviewed and evaluated regularly. Since the previous inspection improvements had been made to the care documentation. However, in two of the four plans examined there was no evidence to show involvement from residents/relatives. Risk assessments were in place where required and were comprehensive. Some attention to detail is needed relating to signatures not in place from the manager or head of care for assessments in the use of bedrails. There was documentation to demonstrate that general practitioners, consultants and other health care professionals are meeting resident’s health care needs. Relatives/residents comments included; I am very pleased with the home, We are happy with my relatives care, she is always dressed clean and tidy, The Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 12 staff members are always very supportive, The staff members are good listeners, The girls are great with me. Policies and procedures are in place for the ordering, receipt, storage, disposal, administration of medication and self-medication. At the time of the inspection there were no residents, who managed their own medication. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. People who use services are able to make choices about their lifestyle. A variety of food is offered. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home employs an activities co-ordinator. At the time of the inspection she was taking maternity leave, however another member of staff had taken over this role and she was very keen and determined to provide activities, for the residents to enjoy. Information regarding activities is kept in a specific file and each session is evaluated. There is also a manual of guidance of activities, which is broken down into the seasons of the year and there are ideas for celebrations for each month. Residents also enjoy games such as bingo and board games. Hand massages and manicures are popular and the manager said there are some changes planned in the hairdressing room to incorporate a ‘nail bar and also have a ‘foot spa’. There are weekly activities, such as flower arranging, cinema club and recently a gardening club had been started and some relatives had donated bulbs. Residents also enjoy entertainment every month. Representatives from different religions regularly visit the home and there is a ‘sing a long ‘ service on a Sunday. Residents interviewed said friends and family could visit at any time and were invited to all the parties and events. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 14 Menus were in the dining rooms, available in written and pictorial form. A variety of food is offered with choices and further alternatives available. Special diets are also catered for. Comments from resident/relative surveys included: The meals are always good and beautifully presented; I always get cups of tea. The expert by experience commented ‘I was able to visit all areas within the Home. I introduced myself to the Chef and the Cook. They told me that residents had a choice for breakfast; they were served with a cooked meal if they so wished, or otherwise had cereals, toast and preserves. The chef told me that if a resident wanted breakfast, lunch, tea etc. in their own room, then that is where the meal was served. I observed the menu board, and there was a good choice of menus. The cook told me that she felt that a happy kitchen was a good kitchen and they had a happy kitchen’. ‘I felt that those residents unable to feed themselves, were very well served by Staff sitting and feeding them, in another dining area, thus ensuring that they, the Staff, knew and were aware of the residents intake of food and liquids. I felt this was excellent practice’. ‘An elderly gentleman who described himself as “being past my sell by date” felt very pleased that he could have a cooked breakfast when he wanted it, described the Staff as very good and caring, he especially mentioned Jo, and felt he was fortunate to be in the Home’. ‘One gentleman said he was unhappy, but said he would not really be happy anywhere other than his own home. He did say however that the staff is good and kind’. ‘One of the residents who told me she had two sons, both living away from home, thus unable to visit as often as both she and they would wish. However she told me that one son had visited her just two weeks ago but she did not think he would be back before Christmas. She thought, and hoped that her other son would be visiting her soon; otherwise she did not have many visitors. She did say she would like to have someone else to talk to from outside the Home. When we discussed how she felt about living in Westmoor, she said she enjoyed it very much “because the staff doesn’t treat you as though you are a blithering idiot, and they are also kind and thoughtful”. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. People who use the service are able to express their concerns and have access to a robust effective complaints procedure, are protected from abuse, and have their rights protected. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Four residents interviewed said that they would be comfortable speaking to a member of staff if they had any concerns. The home has a complaints policy and procedure in place. This has been updated since the previous inspection and includes the Contracts and Commissioning department of the Local Authority. There had been four complaints made to the home since the previous inspection. The records showed that they had been investigated promptly and there were written reports of action taken in place. Three of the complaints were unsubstantiated and one was substantiated, which was regarding a radiator guard preventing heat coming through and required cleaning out. Following the outcome of the investigation complainant is asked if they are satisfied or not. The home has a whistle blowing policy and an adult protection policy in place. There was evidence in the staff training files to show that staff had received training in Adult Protection’. During interviews with staff they confirmed they had received training and were aware of the procedure to follow in the case of suspected abuse and would report any concerns to the manager or person in charge. Westmoor View Nursing Home DS0000000223.V356483.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 & 26 People who use the service experience excellent quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe well-maintained and comfortable environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A senior sister, Jo gave the expert by experience a tour of the home. She commented that her own impression of the home was that it was welcoming, clean and warm and through the leadership at the home, excellent care was being provided to the residents. Bedrooms contained personal possessions and were comfortable and homely. Communal areas were well maintained with lounges looking warm and cosy. Re decoration and refurbishment is ongoing throughout the home. Since the previous inspection several bedrooms have been refurbished and some profiling beds have been purchased. A new carpet was in place in one of the lounge areas, along with some new curtain chairs. A new maxi hoist, which also weighs residents, had also been purchased. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 17 Changes had also been made outside the home, raised flowerbeds to enable residents to participate with the gardening were in place, along with an ‘Arbour’. The patio area had been extended for ease of access for wheelchairs. The expert by experience commented ‘I was impressed by the cleanliness of the Home and the complete lack of unpleasant odours within both communal areas and residents bedrooms. I feel that the cleaning staff should be commended for their extremely high quality standard of work. Comments from resident/relative surveys included: No matter what time I visit the home is always fresh and clean. Westmoor View Nursing Home DS0000000223.V356483.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 People who use the service experience good quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home has a rota in place, which shows a skill mix of staff being on duty on each shift. The home has a policy and procedure in place for the recruitment of staff. Four staff files examined showed that the required information, references and CRB checks were in place prior to staff commencing work in the home. Staffs receive Skills for Care induction training with different handbooks for each job. Each new member of staff has a mentor who guides them through the induction process. The home has a training plan in place and each member of staff has a personal development plan. Since the previous inspection staff had undertaken training in Health and Safety, Fire Safety, Personal Best, Food Hygiene, Palliative Care, Safe Handling of Medication, Pressure Area Care/Wound Management, Catheter Care, Protection of Vulnerable Adults, NVQ 2 and 3, Care Planning/Quest and Chefs Best. 58 of staff has achieved NVQ level 2 or above in care with a further six staff working towards the qualification. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 19 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 People who use the service experience excellent quality outcomes in this area. The management and administration of the home is based on openness and respect and has effective quality assurance systems. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The Manager is a qualified nurse and has achieved the Registered Managers Award. She has many years experience in care services. Several quality assurance systems were seen to be in place focussing mainly on care documentation, activities and medication. There are also monthly audits looking at accidents, pressure sores, fire safety and maintenance both internal and external. The Area Manager carries out monthly visits and reports on many aspects of the home, the building, care records, health and safety and also has discussion with residents and staff. Questionnaires are sent out annually to residents to seek their views about life in the home. At the time of the inspection a ‘customer survey’ had only recently been carried out and the Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 20 manager was sending the sealed responses up to Headquarters. Following the completion of the survey an action plan would then be formulated for any areas required. Resident and staff meetings are held regularly and minutes are kept. A number of health and safety documents and records were examined at the inspection including the accident book, the gas safety certificate, hot water temperatures and various other records. These were all found to be up to date. A check of residents’ finances and records was correct and showed that any monies kept on behalf of residents is in safe hands. Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 21 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 3 Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Signatures must be in obtained from either the resident, or their relative when not possible to show resident involvement in the review of their plan of care. Timescale for action 29/02/08 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 Westmoor View Nursing Home DS0000000223.V356483.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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.V356483.R01.S.doc Version 5.2 Page 24 - 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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