Inspection on 27/01/06 for Westoe Grange

This inspection was carried out on 27th January 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 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

Westoe Grange 27/02/07

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 Westoe Grange 4 Horsley Hill Road South Shields Tyne and Wear NE33 3DY Lead Inspector Mrs Eileen Hulse Unannounced Inspection 27th January 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 Westoe Grange DS0000064791.V267899.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 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. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westoe Grange Address 4 Horsley Hill Road South Shields Tyne and Wear NE33 3DY 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) 0191 5374676 0191 4558691 Mr Trevor Nesbit Mrs Carol Barbara Durdey Care Home 40 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (40), of places Physical disability (1), Physical disability over 65 years of age (5), Sensory Impairment over 65 years of age (3) Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Westoe Grange is a modern, purpose-built care home that is close to the centre of South Shields and a number of local amenities. It is registered to provide personal care for up to 40 older people, including a small number of places for older people with physical, dementia care or sensory needs. The home is a 3 storey building with offices and service areas on the lower ground floor. Service users’ accommodation is in 40 single rooms on the ground and first floors with all bedrooms having en-suite facilities. There are 2 main lounges and dining room, and a conservatory offers a smoking area. The entrance is on the side of the home and the courtyard driveway offers parking for several cars. The home does have a small garden area, which provides a pleasant area for service users to sit in better weather. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 27th January 2006 by one inspector (Eileen Hulse), it was un-announced and was carried out as part of the annual inspection programme. It took 8 hours to complete that included 1hour to prepare for the inspection. The focus of the inspection was to gain insight into the quality of life and services received by service users who live in the home. Time was spent chatting to service users, talking to relatives and with the Manager and staff who were on duty to gain their views on the service provided at Westoe Grange. Some records were inspected that included a sample of care plans and needs assessments, medication arrangements, protection of adults policy and procedures, social activities, risk assessments, staff personal files and qualifications and service users finance arrangements. A tour was made of the premises and a lunchtime meal was taken with the service users. What the service does well: The home provides a good standard of care in a home that is comfortable and nicely furnished. The staff team are caring and committed to their roles and treat service users with dignity and respect and this is reflected in their everyday practice. Service users were very positive about the service they receive, and during discussions with them, they made the following comments: • • • • ‘I have been here three months now and have really settled myself’ ‘I go to bed when I want, usually when I am tired at 11pm’ ‘I’m quite alright living here’ ‘Some staff are nice but some are haughty taughty, but that’s just the way they are’ The mealtime arrangements in the home are good and service users discussed continually about all the good meals they receive and the choice surrounding the food they eat. Good training is offered so that the skills and knowledge of staff is updated on a regular basis. What has improved since the last inspection? Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 6 The home now has a good quality assurance system that is used to monitor the service they provide and to make sure that service users receive the care they expect. Staff have accessed more training and have gained further qualifications. 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. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 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 Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The home does not provide intermediate care at this time. EVIDENCE: Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Every service user has an individual plan of care but they do not contain sufficient information. Without detailed information, the home cannot be sure that the care needs will be met. Medication arrangements are good and ensure that medicines are stored correctly and that service users are given medicines safely. EVIDENCE: A sample of care plans were examined and varying levels of information are included within them particularly in areas regarding personal care needs. One care plan states the service user can only walk short distances and informed staff that the service user must be encouraged to mobilize but it does not give staff any guidance on the distance they can walk or how staff should encourage the service user. They do not always include the likes/dislikes and evaluations are not completed that would give staff the information that the plan was working or changes needed to be made. They do not give descriptive detail to guide staff practice and some of the entries made on the monitoring sheets are very repetitive, one service user who has epilepsy does not have a care plan to guide staff on how the condition can be managed or what action they should Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 10 take should an emergency take place. More detail needs to be included to ensure the care needs are met at all times and that the care is consistent. A detailed policy and procedure on the handling and storage of medications gives good guidance for staff and follows the Royal Pharmaceutical Guidelines. It describes the layout of the medicine administration charts and gives good guidance on how to administer medicines, the storage of medicines and the disposal of unwanted medicines. Three service users living in the home have control of their own medication and were all found to have appropriate lockable space within their bedrooms for storage. A sample audit of the medicines and records were checked and all were well maintained and up to date. The temperature of the fridge is taken every day, which is located in the medical room and holds medicines, which require refrigeration. Oxygen bottles and medication trolleys are securely stored and fastened to the wall. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Although there is a weekly programme of activities available to service users that are organised by staff, the home would benefit from employing an activities co coordinator. This would free staff to carry out other roles within the home. It was evident that there is good progress being made to maintain contacts with the local community and service users are encouraged to maintain contact with their families and friends. Service users are offered and receive varied and nutritious meals that can contribute to their general well being and health. EVIDENCE: There is a weekly programme of activities on display in the main hallway that gives service users the information to choose if they wish to participate in them. The activities include weekly trips out for those who wish to go out in small groups to local places of interest and there are occasional evening social events, parties and entertainment. During discussions with some of the service users they stated they were satisfied with the activities and social events on offer at the home, although some people prefer not to join in at their own choice. Comments service users made included: • • ‘If the home goes out I always go with them’ ‘They see I get my newspaper everyday’ DS0000064791.V267899.R01.S.doc Version 5.1 Page 12 Westoe Grange • ‘I like a bit chat to the staff and that suits me for activities’ It is recommended an activities co-ordinator is employed by the home. Service users have good contact within their local community as they use the local shops everyday and enjoy several trips out every week. The manager also explained that Age Concern come into the home to give computer training for service users and one service user goes independently to a pop in day centre. Service users have visitors in the privacy of their bedrooms or in the numerous sitting areas throughout the home. One visitor joins her relative for tea whenever she visits and relatives are encouraged to be involved with the care of their relative, records evidenced this is well documented within the personal plans of care. The inspector had lunch with the service users and the arrangements in place were good, tables were well set with placemats, condiments and serviettes. It was a three course meal comprising of mushroom soup with a choice of either fish, cooked in a variety of ways or ham salad with chips or mashed potatoes, peas and bread and butter with plums and custard or yogurt for sweet. The meal was hot, tasty and well cooked with good sized portions. The atmosphere was good with service users chatting with each other throughout the meal. Service users were given sufficient time to sit and enjoy their meal without being hurried and those requiring help with their meal were assisted by staff in a sensitive and dignified manner. Some service users spoke positively about the meals they receive and comments were as follows: • • • • • ‘The food is really good here’ ‘We had a good cooked breakfast so I am never hungry at lunchtime’ ‘One of the girls came 2 hrs ago to ask me what I wanted for tea, they are really good’ ‘The meals always taste nice and they are always well cooked’ ‘We have a very good cook here’ Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home have good policy and procedures on the protection of vulnerable adults and this helps to keep service users safe and protected. EVIDENCE: Detailed policies and procedures from South Tyneside Local Authority are in the home and they are made available to staff for information and guidance should they suspect any abuse has taken place and all staff employed by the home have received protection of vulnerable adults training. Recently a POVA incident took place in the home and records evidenced that this was dealt with effectively and efficiently. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home is clean and well decorated offering service users a homely environment in which to live, however, the smoking area should have doors fitted so that the smoke does not filtrate the dining area and the area is safe for service users. The home is clean and well maintained with no unpleasant odours making it a comfortable place for the service users who live there. EVIDENCE: The smoking area is an open recess off the dining room and smoke is able to drift into the dining area not only making it unpleasant for non-smokers but dangerous should fire break out. Doors must be fitted to this area and an extractor installed. The staff rota evidenced that good domestic staffing levels are maintained and each domestic member of staff has their own areas of responsibility for cleaning within the home. They also have very detailed cleaning schedules that helps to guide their everyday practice and all staff have recently completed decontamination and infection control training. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The company have a good staff training profile and the amount of staff with a qualification is impressive, this ensures staff have the skills and knowledge to appropriately care for and support service users. EVIDENCE: All staff have an individual training manual that details the dates and names of courses they have attended, training needs that have been identified, copies of certificates and courses attended. The service employs nineteen care staff and currently seventeen staff has attained an NVQ qualification. There are 5 domestic staff and 4 of them have achieved Level 1 in NVQ housekeeping and the staff team are currently completing a distance learning twelve week accredited training course in food hygiene and safety. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 A good quality assurance and monitoring system is in place to monitor and measure the success of the service, this has recently been expanded upon to ensure that all aspects of the service are reviewed on a regular basis. Throughout the inspection, staff were observed to adhere to health and safety guidelines at all times ensuring that service users are kept safe. The home’s practices actively encourage service users (or their representatives) to continue to manage their own finances. Money and corresponding records were checked and found to be well maintained ensuring that money belonging to service users is safe. EVIDENCE: The Manager has worked hard to develop a quality assurance system so that service users, their families and staff employed in the home can give their views on the service provided. The quality assurance areas consist of an annual development plan for the coming year and is divided into sub areas that Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 17 will have six monthly checks carried out for example, on the policies and procedures, staffing, complaints, activities and care plans. A questionnaire has been sent to service users and their families or representatives to gain information on their views about the service. Information gained from the questionnaires will be used to assess the service currently being offered and to make improvements where necessary. Several service users retain the responsibility for their personal finances some people retain their own pension books. The home stores small amounts of individual service users’ monies for safekeeping, and records are maintained of any transactions carried out on behalf of service users. A sample of financial records were checked and found to be correct and well maintained, information is recorded and stored in line with the Data Protection legislation in individual recording books. However, pages within the books must be numbered, there must be two signatures for every transaction and all the receipts on money spent must be numbered to correspond with entries made in the books. Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 2 X X 3 Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 15 Requirement The care plans must include more information to guide staff to ensure service users care needs are being met (Previous timescale of 01 Sept 2005 not met) The home must employ an activities coordinator to ensure activities are offered on a daily basis The smoking room must have doors fitted so that smoke does not drift into the dining area (Previous timescale of 01 Sept 2005 not met) Records detailing service users finances held by the home must have two signatures, numbered pages and receipts must correspond with entries made Timescale for action 01/04/06 2 OP12 16 01/04/06 3 OP19 23 01/05/06 4 OP35 17 01/04/06 Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 20 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 Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Westoe Grange DS0000064791.V267899.R01.S.doc Version 5.1 Page 22 - 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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