Inspection on 30/04/07 for Westside Care Home

This inspection was carried out on 30th April 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

Westside Care Home 03/11/05

Westside Care Home 03/02/05

Westside Care Home 26/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Westside Care Home Westside Nursing Home 106 Foxley Lane Purley Surrey CR8 3NB Lead Inspector Michael Williams Key Unannounced Inspection 30th April 2007 9:30am 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 Westside Care Home DS0000019046.V332738.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. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westside Care Home Address Westside Nursing Home 106 Foxley Lane Purley Surrey CR8 3NB 020 8660 6453 020 8668 0210 hillho@freenetname.co.uk 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) Hill House Nursing Home Limited Mrs Mary Sogeler Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: Westside is a care home establishment registered to provide personal care, including nursing care, for up to 31 older persons. It is located to the South of Croydon in Purley and is close to the Purley crossroads (A23/A22). The property is a large detached house, traditional brick built and pitched roof style. The accommodation is on three floors and comprises 20 single bedrooms and 4 double rooms and a triple bedroom that is now used for two service users. Twelve bedrooms have en-suite facilities. There are three day-rooms or lounges including an open plan dining area. Other facilities include toilets on each floor and 8 bathrooms including assisted baths and two shower-rooms. The home has a garden to the rear and parking to the front of the premises. Fees in April 2007 were from £620 to £820. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. Westside is one of a pair of Homes owned and managed by the same company Hill House Ltd and therefore many of the outcomes, for example administration, staff training and recruitment, are the same for both homes and this will be reflected in this report. To monitor all aspects of care the Commission ‘tracked’ the care provided to a sample number of residents and cross checked the information by examining the documentation supporting care, observing the meals provided, checking the arrangement for medication, for handling money, records of complaints and accidents. Staff providing care were interviewed, and where possible the inspector met with relatives as well as interviewing or observing the residents themselves. Questionnaires were also distributed and we received written comments from 6 residents, 15 relatives, 6 members of staff and 6 health or social care professionals. All commentators agree Westside provides satisfactory care and some respondents describe the home as “excellent”. What the service does well: What has improved since the last inspection? What they could do better: A number of points were identified as needing attention; this includes the need to ensure no bedroom fire-doors are wedged open any longer than it takes to move residents from one area of the home to another. Improvements are needed for the storage and administration of medication; in particular medicines must not be transferred from the chemist’s pack to a set of labelled pots. Not all radiators in bedrooms and bathrooms have a protective cover but it is to be noted on the day of inspection the temperature of these radiators were not excessively hot. A small number of residents said dinners are Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 6 sometimes late in arriving at the table and would ask staff to make sure meals are hot enough when served. A Director of Westside has given an undertaking to correct these matters and as the Commission is confident these matters will be attended to no requirements are made but recommendations are made to ensure improvements are sustained. 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. Westside Care Home DS0000019046.V332738.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 Westside Care Home DS0000019046.V332738.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): NMS 3: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. New service users are being admitted only on the basis of an assessment undertaken by people trained to do so. This involves the service user or, in some cases their representatives, so they will be assured that their needs will be met. EVIDENCE: Apart from minor changes need to the Statement of purpose, the Commission’s post code for example, it is otherwise a well presented document which prospective service will find most helpful. Most residents admissions involve professional agencies including hospital doctors, nurses and physiotherapists. They provide clinical information to assist the home in evaluating residents’ needs prior to admission and so ensure they will met. The home also has its own very detailed assessment formats. Feedback to the commission indicates that prospective residents get the opportunity to visit and get to know the home before making a decision about whether or not to stay. In the written comments notes we received we were Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 9 advised that this home compares favourably with other homes they have visited before deciding to use Westside. Areas of strength are the detailed assessments that take place prior to admission, the accessibility of the home for prospective residents to visit and evaluate services prior to admission and the information such as the Guide provided by the home at the time of admission. Westside Care Home DS0000019046.V332738.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): NMS 7 to 11: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning, the provision of health care and the procedures for dealing with medication are not only satisfactory in this home but in many instances achieved to a very high standard - this ensures the often complex social, and health care needs of residents can be met. EVIDENCE: The home has systems in place to ensure care plans are reviewed at least monthly and updated regularly. The format of the care plan used in this home are written in a clear and informative manner which enables staff to be able to have an understanding of residents care needs and any changes that might have occurred in their condition. It is very positive to be able to report that these changes do not always indicate a deterioration but in many cases an improvement in a resident’s condition which is indicative of the excellent care provided in this care home. Feedback and involvement is a continuous ongoing process; the inspector confirmed that staff spend time with individual residents to ensure they understand their needs, although some feedback indicates staff are often very busy. The care plan is in the form of a standard set of forms that are easy to understand and are used as a working tool and is Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 11 understood by all care and nursing staff. Because it is a standardised, colourcoded format written in clear language it could be used in an emergency by people who are not familiar with its content, for example we were able to identify key factors when we examined these care plans. The residents’ care plans include risk assessments and the management of risk takes into account the care needs of residents balanced with their aspirations for independence and choice and this is particularly true of residents who have a strong opinion about how they will spend the day and what activities they will take part in during the week. For example many residents like to spend their day in their private quarters and are free to do so if that is their wish. When couples live in Westside they are given choice about how their rooms are arranged so as to be together or in adjacent rooms if they prefer. The home medication policies, procedures and practice guidance ensure the safety administration of medication. However one anomaly was identified in that some medicines were being transferred from the original pack into a small pot and taken to the resident on another floor and the chart signed a little later. Concerns were raised as this process could be open to error, and because of this the senior nurse agreed to find a better system for delivering medication directly from the pack and to sign for it at the time of administration to each resident. A recommendation is therefore made to store medicines in a location that will help improve the administration of medication. The manager very much values residents’ views about how they are being cared for and this was demonstrated by the considerable number of feedback forms received by the Commission and the many letters of commendation sent to the home itself. This home provides care to residents who often have complex clinical needs and we ‘case tracked’ a number of such complex cases and this included an examination of case records; interviewing residents and by talking to family and to staff. It is to the credit of Westside that a number of residents arrive in the home with an expected life span counted in weeks or days but in fact their health and quality of life improves and it is not unusual for their life span to be extended considerably longer than anticipated. The wishes of individual residents about dying and terminal care, and the arrangements they want after death are openly and sensitively discussed with both the residents and their family during the development of the care plan – although not everyone wishes to discuss this in any great detail. Nevertheless Westside ensures a resident’s last days are sensitively and well managed in consultation with the resident, their family and care staff. How death will be managed is clearly recorded, respected and known to the staff delivering the care. The home has a detailed policy, procedure and practice guidance to help staff when handling terminal care and death. All staff receive in house training and practical advice in caring for residents who are near to death, and have continuous support and opportunities to discuss any areas of anxiety and concern. Facilities are provided to allow relatives and friends to stay with the resident and to assist with their care if a resident wants this. A palliative care nurse commends the home as ‘one of the better homes in the area, patients Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 12 are well cared and palliative care needs are met’; for this reason the home is judged as excellent in this section of the report. Areas of strength include the home’s capacity to provide high standards of care, social and clinical, in complex cases. There are no matters identified as requiring improvement, but one recommendation is made about delivering medication to residents, so this section, about health and personal care, is assessed as excellent. Westside Care Home DS0000019046.V332738.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): NMS 12 to 15: Quality in this outcome area Excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from limited only by their own choice or incapacity. The home has sought the views of residents and visitors and has considered their varied interests and abilities when planning meals and the routines of daily living and arranging activities. Routines are very flexible, within the constraints of large establishment, and residents can make choices band exercise control in major areas of their life. The routines, activities and plans are resident focussed, regularly reviewed, and can be quickly changed to meet individual residents needs. EVIDENCE: The home has a new activities coordinator who is responsible for creating meaningful activities both within the home and in contact directly or indirectly with the wider community. On the day of the inspection many residents were gathered together in the main lounge after lunch and they spoke very highly of the programme of activities provided by the home and particularly enjoy the quizzes and word puzzles – a type of activity that allows them to show that their mental faculties are not failing even if they are physically frail. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 14 The systems in place and the practice and attitude of the staff team give service users the opportunity and support to remain independent particularly when residents have definite ideas about how they will spend their time each day. However it is inevitable that in many instances residents are far too frail to be independent and are in fact very dependent upon staff for all aspects of their care. But even in such circumstances the home seeks to ensure residents are stimulated and kept mentally active. One excellent example is a resident who by can now occasionally vocalise and is an example of hard staff work to stimulate and engage with residents. Such progress is also very rewarding for the care staff. Other more active residents still get out and about despite frailty and disabilities. Family and friends were on site to advise us that they are welcomed into the home and can either meet residents in the communal areas, in private areas such as the quiet lounge or in resident’s own bedroom. Food is recognised as very important and meal times considered a social occasion. Meals are prepared off-site and delivered in hot trolleys. The chef for the both the proprietors’ care homes is qualified and has a lot of experience cooking for older people. He is seen as an important member of the care team and familiar with the dietary and cultural needs of each resident in this and the other home for whom he prepares meals. He is committed to involving service users in menu planning and making sure that they are able to enjoy the food they prefer and like and frequently makes extras meals for residents who dislike the main choices or choose not to have the main choices as a matter of personal preference. The menu is varied, balanced and nutritious. It has a number of choices including a healthy option, and includes a variety of dishes that encourage service users to try new and sometimes unfamiliar food. Food is served to meet the needs of all residents including those who have swallowing or chewing difficulty. Staff give assistance to those service users who need help to eat, and when doing so they are discrete and sensitive. Mealtimes are relaxed, staff are patient and helpful, and allow service users the time they needed to finish their meal comfortably, encouraging them to serve themselves. Residents appreciate the good quality food they are served and being able to have a drink when they wish and the availability of snacks. They also enjoy being able to eat in their own room when they wish. Whilst the home does not have kitchenettes, for residents to prepare their own meals, the home nevertheless endeavours to meet individual choices about food in a very flexible and patient way. Areas of strength include the very popular activity programme; the comfortable environment and the exceptionally good catering and as no matters requiring improvement arise this section, about daily living, is assessed as excellent. Westside Care Home DS0000019046.V332738.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): NMS 16 18: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home has a clear and simple procedure for dealing with complaints so residents are confident their concerns will be dealt with promptly and effectively. To ensure service users are safeguarded from abuse the home has a comprehensive training programme as well as written policies and procedures. EVIDENCE: Westside has an up to date and clearly written complaints procedure that is easy to understand and follow. The company can make available in a number of formats to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is well circulated around the home and in the home’s guide and on notice boards – but even so a number of feedback forms indicate that not everyone knows what the complaint procedure is. However, when we spoke to residents and their visitors in was clear they had a good understanding of how to make a complaint and to whom they might complain. They were also very clear about how complaints will be handled. The home contends that unless there are exceptional circumstances the manager or one of the Directors always responds to complaints within the agreed timescale – although some practical problems may take time to fix. The policies and procedures regarding protection of residents are of a high quality and are regularly reviewed and updated – for example when the local authority revised its guidance. The service is clear when incidents need external input and who to refer the incident to. Training of staff in the area of Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 16 protection is regularly arranged by the home. The outcomes from any referral are managed well and issues are usually being resolved to the satisfaction of those involved. This would include disciplining staff where lapses in conduct have been identified. Residents and others associated with the service tell us that they are very satisfied with the general care and services provided at Westside and they tell us that they feel very safe and well supported by the manager, the staff and Directors who are frequent visitors to the home. The promotion of the individual’s rights is central to the aims and objectives of the services and this is spelt out in their Charter. Policies, procedures. Most of the home’s documentation reflects the rights of the individual as declared in their Charter. Advocates are used to help residents understand their rights, and to also ensure that they can access places of worship or community facilities of their choice. We met one such advocate to confirm this is the case. Staff are skilled and understand the importance of actively promoting individuals rights, for example they understand residents’ rights to privacy, to direct their daily lives, to make choices (within the limitations of their abilities and disabilities) and to accept or reject treatment and support as they wish. Areas of strength include the willingness of the home to listen to concerns and complaints and act upon them. Staff have demonstrated a clear understanding of the procedures for protecting vulnerable adults. No matters requiring action are identified so this section, about complaints and protection, is assessed as good. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 17 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): NMS 19 26: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The layout of the home and the manner in which it is being maintained means ensures that this is a safe, comfortable and suitable environment for the service users. The premises are being kept clean, hygienic and free from offensive odours and systems are in place to prevent the spread of infection. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live with many bedrooms rooms that meet the national minimum standards including en-suite facilities. Where rooms are shared it is only by agreement, and screens provided for privacy. Residents are given the choice to move into a single room when one becomes vacant. They have the choice to bring small personal items of furniture into the home. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy, in the small quite lounge for example, or in their own bedrooms. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 18 There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. Residents say that there is plenty of hot water and the temperature in the individual bedrooms can be adjusted upon request. The home is well lit, clean and tidy and free of offensive odour. The management has a good infection control policy. They seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. Residents commend housekeeping in Westside. A rolling programme of renewal and replacement is in place and recently the ground floor communal areas including the dining room were redecorated – the combination paint and wallpaper provides a practical and attractive finish. Inevitably some areas need attention including areas where chairs cause superficial damage to walls, doorways and tiles. Not all bedroom doors have a door lock and not all radiators in high risk areas are covered. An unprotected radiator was identified in a bedroom - although it was noted that this radiator was not excessively hot and therefore did not pose any immediate danger to the resident. Areas of strength are comfortable surroundings in which residents live, the home is clean and tidy and well equipped to cater for residents with mobility problems. Amongst those matters recommended for attention are the installation of bedroom doors locks; the need to ensure all radiators are assessed to ensure they pose no risk to residents and the installation of a suitable magnetic door-holding device for residents who wish to leave their bedroom door open. This section, about the environment, is assessed as good. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 30: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home which ensures that their needs are being met. The required procedures are in place to ensure recruitment of staff protects service users. The home has a staff induction, training, support and supervision regime in place so service users can be assured that staff are competent in their jobs. The recruitment, training and support of staff will ensure service users are ‘safe in their hands’. EVIDENCE: Residents have confidence in the staff that care for them, often describing them as very caring and thoughtful. Rotas show well thought out, making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. This includes moving key staff from one floor to another as overall dependency levels alter. Management encourage staff members to undertake external qualifications beyond the basic requirements, and recognise the benefits of a skilled, trained workforce. For Nurses this means maintaining their qualifications and skills through recognised training and practice sessions throughout the year. The service clearly defines the roles and responsibilities of staff, nursing, caring and ancillary, through accurate job descriptions and specifications. Residents report that staff working with them are very skilled in their role, and are consistently able to meet their needs. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 20 The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. Feedback to us from external trainers confirms the staff not only undertake relevant training but are enthusiastic and keen to learn. The service has a good recruitment procedure that clearly defines the process to be followed. A number of staff files were examined and staff interviewed to confirm this procedure is followed in practice. Westside clearly recognises the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. There is little use of any agency or temporary staff. The general judgement of visiting professionals (doctors, nurses and other), is that this is an “efficiently and well run home with very caring and skilled staff”. Areas of strength are the number, qualifications and skills of staff and as no matters requiring improvement arise in this section, about staffing, it is assessed as good. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 21 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 32 33 35 36 37 38: Quality in this outcome area excellent. This judgement has been made using available evidence including a visit to this service. The owners and manager are registered with the Commission as persons competent to run Westside in accordance with its stated aims and objectives and so in the best interests of the service users. The home is well managed, including its finances, and is safe and viable for the benefit residents. EVIDENCE: The manager has the required qualifications, including nursing qualifications, and has considerable experience - making her very competent to run the home. The Manager works closely with the Directors, who themselves are closely involved in the day to day running of their two care homes, and as a management team they strive to continuously improve services and provide an increased quality of life for residents. The Commission has noted that there is a strong ethos of being open and transparent in all areas of running of the home. The manager and Directors are ‘resident-focused’ and they lead and Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 22 support a strong staff team who have been recruited and trained to a high standard. The manager is aware of current developments both nationally and by Commission and plans the service accordingly. The home has sound policies and procedures, which the management team periodically review and update. The manager is regarded highly by other professionals as affirmed in their feedback to us, describing the home as “excellent”. Management processes ensure that staff receive feedback on their work through regular formalised meetings such as the staff meetings and supervision meetings and through informal contact during the working day. The home works to a clear health and safety policy, all staff are given a copy, and regular random checks take place to ensure they are working to it. The home has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. A range of records were examined during the inspection visit including residents’ case files; staff files; food records; money records; medicine records; complaints; accidents and so forth. Where issues have been identified, for example, in care plans, these have been acted upon successfully to ensure residents’ care is not compromised. Residents have confidence in the safe working practices of staff. The Directors clearly have the skills and ability to deliver good business planning, effective financial controls and provides a quality assurance and monitoring processes. They confirm that the home remains financially viable. Insurance cover in place to enable it to fulfil any loss or legal liabilities. If they wish and are able to, residents are helped to take responsibility for managing their own money and some do. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for resident’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. A sample of money records were checked to ensure these records are maintained with probity and efficiency. In respect of safety matters the home needs to review radiators to ensure none will pose a risk to residents because at least did not have a protective cover (mentioned under the environmental standards) and the administration of medication (mentioned under standard 9) needs to be reviewed to ensure safe practice is not compromised by transferring medicines into alternate containers. Some residents would like to have their bedroom left open so the home needs to consider a safe method for doing so, such as, a magnetic door holders. Areas of strength are the overall management of the service as confirmed by feedback to us and as observed during inspections and information sent to the Commission. Matters requiring improvement are listed under other sections, such the need to confirm the current bedroom doors meet safety and privacy standards and medication procedures. This section, about management and administration, is assessed as excellent. Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 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 4 4 4 3 3 3 4 3 Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Medicines: It is recommended that the home ensure safe practice can be maintained by reviewing the storage and administration of medication so need to transfer medication in alternate containers and there is no delay between giving the medicine and signing for it. Bedroom doors: It is recommended that bedroom doors are fitted with suitable locks to provide complete privacy when required. Bedrooms: It is recommended that radiators in residents’ bedrooms and ensuite units are reviewed to ensure none pose a hazard or risk of injury. Bedroom doors: It is recommended that if residents wish to have their bedroom doors held open a suitable magnetic device is installed. 2 3 4 OP19 OP19 OP19 Westside Care Home DS0000019046.V332738.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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