Inspection on 01/11/06 for Westside Home

This inspection was carried out on 1st November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Westside Home 32 Scarle Road Wembley Middlesex HA0 4SN Lead Inspector Richard Adkin Key Unannounced Inspection 1st November 2006 07:30 Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 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 Home DS0000066707.V314940.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westside Home Address 32 Scarle Road Wembley Middlesex HA0 4SN 020 8782 1516 020 8782 1516 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Kemi A Beckley Mr John Femi Beckley Mrs Kemi A Beckley Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection No previous inspection new service. Brief Description of the Service: Westside Home is a home for three residents with mental health problems. The home is located in a street close to Wembley High Road with shops, amenities and transport connections. There are several parks close by. There is off street parking for two cars. There are three spacious bedrooms for residents including a staff room/sleeping-in-room. There is a shower room with toilet on the ground floor and one bathroom on the first floor. Fees are approximately £996.00 per week depending of complexity of needs. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for this newly registered care home. It was an unannounced inspection that took place early morning midweek in November; a follow up visit took place the following week as interviews were taking place throughout the day. Currently there are two residents with one further resident beginning the assessment process. Opportunity was afforded to meet with the two current residents, the registered manager/provider and her partner and a staff member. A tour was made of the premises and records and policies and procedures looked at. The Inspector would like to thank staff and residents for contributing to the inspection and for the warm welcome. What the service does well: What has improved since the last inspection? This was the first inspection as it is a new service. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 6 What they could do better: Several requirements arose at this first inspection. Residents’ health checks must be systematically monitored and recorded. The POVA policies and procedures for the two referring authorities must be available in the care home. The garden is in need of landscaping though there are plans to take this forward in the spring. Fire drills must be carried out and weekly testing of alarms and emergency lighting must be recorded. It is recommended that the staff team undertaking training on working with and managing challenging behaviour and breakaway training. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 7 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. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place if the care home is confident that the staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. EVIDENCE: The key standard addressed was to establish that prospective user’s individual aspirations and needs are assessed. This was discussed with both residents by the Inspector and their personal files looked at. The home manager/proprietor guided the Inspector in the process of assessing the individual service user’s needs and their aspirations. Both residents had full assessments undertaken by members of a multidisciplinary team responsible for the service user’s care package. Both residents are subject to CPA (Care Programme Approach and Section 117 After Care (1983 Mental Health Act). One Resident is subject to a Section 37/41 Home Office Order and there are comprehensive assessments in place. There is a Service User’s full care plan in place for both residents. This is drawn up at the point of commencing at the care home. This is signed by the service user, carers, Care Coordinator, Home Manager and advocate where appropriate. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 10 The plans are comprehensive and detailed with clear action plans and desired outcomes. Where appropriate, the views and interests of family members, with the service users’ permission are taken into account and recorded. Admissions to the home only take place if the manager feels that the care home can significantly meet the complex needs of service users being referred. The manager discussed several referrals that the home could not accept at this point in time because of the risks involved in managing the challenging behaviour. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective systems in place to ensure that the care plan is reviewed and updated. Care plans are robust. The home promotes independence balanced with risks that are assessed and considered. EVIDENCE: The resident’s needs are comprehensively assessed by the referring multidisciplinary team and by the care home. The changing needs, personal goals and restrictions on choice and freedoms (as determined by the CPA programme and Mental Health Act 1983) are clearly laid out and discussed and agreed with the residents and signed by the residents. Evidence was seen of evolving needs being identified and responded to. The manager was particularly alert, knowledgeable and in tune with the evolving needs of the residents. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 12 There was evidence of both the resident’s plans being reviewed regularly and being working documents that informed and reflected practice. Each resident has a main key worker at the care home; a cultural match has been made for each key worker with the resident to further support meeting the residents’ cultural needs. Calculated risks are taken with one resident with mobility issues and some challenging behaviour. Her independence is fully supported by the staff group in discussion with her carer and the resident herself and reflected in the care plan. This support of risk has enabled residents and promoted independence. The risks for the other resident are more prescribed given the nature of the Home Office Order, but supportive engagement was observed and noted in the records. One resident’s pattern and scale of smoking behaviour has been sensitively modified with the support of a family member, but with the resident maintaining a sense of being in control. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in being independent and taking part in age and culturally appropriate activities. Visiting arrangements are open. Eating arrangements are flexible and food preferences are met. EVIDENCE: The two residents have only been at the care home for the last few months given that the care home has recently opened. In discussion the Manager is aware of meeting the cultural, religious and diversity needs of the residents. Both residents spoken with by the Inspector felt they were treated well at the home. The Manager and staff on duty during the two visits were observed to engage sympathetically and respectfully with the two residents. A newly forming staff team were actively promoting opportunity for the two residents in involving them with the local community reflecting their disability or cultural/religious needs. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 14 One resident was supported in engaging with the local mosque and the home had made the link with the Horn of Africa Project and an opportunity was opening up to follow up vocational skills that had been dropped because of hospitalisation. The other resident was being supported in linking with the local Mind Rainbow Group for mature people with mental health problems. A key worker system and cover key worker is in place. Each resident has a phone in their room to support contact with family and friends and each resident has their own front door and room key. A strong warm welcome is given to visitors of the residents. Positive comments from one carer were seen by the Inspector. On both visits there was a full fruit bowl for residents. There are menus drawn up, but there is adaptability in what is served. Halal meat is bought for the resident who is a Muslim. The serving of food is flexible to support the lifestyles of residents. Both residents spoke favourably about the food cooked at the care home. Residents can choose where to eat. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in their personal care and encouraged to be independent and responsible for their own personal hygiene where possible. The medication practice is being further improved. The home works towards meeting the physical and emotional needs of residents. EVIDENCE: The Manager and staff seemed in tune and sensitive to supporting one resident with physical difficulties in showering. Staff were clear when they helped and when they left the resident to self care. Prompting and support was evident for the other resident in encouraging self care. Records are kept of bathing/showering. Both residents have been registered with a local GP. The Manager had persevered with the registration, particularly of one resident because of his immigration status. A referral had been made to the GP for one resident who had gained weight and an exercise regime and referral to a gym were being followed up. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 16 One requirement arose. This concerned the systematic recording and following up of physical health checks for residents around dentistry, opticians, chiropodists etc. The mental well being of both residents is carefully monitored and supported and planned. Staff were observed to be engaging with residents respectfully. There are strong links with multi-disciplinary teams, which is a requisite for the resident subject to Section 37/41. Privacy and dignity is given attention. The Inspector looked at the Medication Policy for the care home (which is the Mulberry Group policy). The medication is stored in a locked cabinet in the staff room. Training had just taken place with Boots around medication and the home was on the point of transferring to the Boots system. Medication records looked at by the Inspector were up to date. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and distributed within the service. The promotion of individual’s rights is central to the aims and objectives of the service. EVIDENCE: Staff undertook POVA training in September 2006. Further POVA training is Booked for January 2007 with the London Borough of Brent. A requirement arose as the POVA policies and procedures for the two referring authorities from where the current residents originated or were funded needed to be in place. The POVA policy for Brent was unavailable. No complaints were recorded or had occurred according to the Manager. One incident had been appropriately reported to CSCI and acted upon. The complaints procedure is contained within the Service User Guide; the complaints procedure is also discussed with relatives. From discussion with the Manager and the two residents, it was evident that the Manager and staff listen to and act upon the views and concerns of residents and other key people and that discussion is encouraged and action taken on issues raised. A difference that arose between the two residents was acknowledged and addressed. Potential physical and verbal aggression is understood by the Manager and staff and is carefully managed and dealt with appropriately. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 18 Risk assessments and records reflect actions that are to be taken and considered and agreed preventative steps. Uppermost in the objectives, practice, records and policies of the home is the promotion of the individual’s rights. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe comfortable and attractive. Residents’ needs are addressed in the layout of their bedrooms and the home. The shared areas provide a choice of communal space. EVIDENCE: A tour was made of the premises by the Inspector. The home on occasion of both visits was clean and hygienic and reasonably decorated throughout. Laundry facilities are sited before the kitchen in a contained area thus clothing and linen are not carried through areas where food is stored, prepared, cooked or eaten. There was a lack of paper towels in both the bathroom and shower room, but a towel dispenser had been ordered and was due to arrive and be installed. The downstairs shower felt damp and the extractor fan was not functioning which must be addressed. There is a maintenance person who visits weekly and necessary repairs are noted in a book. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 20 The garden at the back was bare, but plans are drawn up and a contract in place for the landscaping work to begin in spring. One resident with a physical disability has a bedroom on the ground floor with good access to the ground floor shower room. The three single bedrooms of residents are spacious and adequately furnished. Residents have personalised their rooms; the resident on the ground floor is supported in her lifestyle and wishes in using her bedroom as living space. The home offers access to local amenities and transport systems and this compliments the personal and lifestyle needs of residents; the home is in keeping with neighbouring houses and has a domestic feel to it. Residents can eat in the kitchen or living/dining area or their own room if that is their agreed choice. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have confidence in the staff that care for them. Recruitment procedures are defined and practiced. An induction programme is in place; staff are well supported in their role. EVIDENCE: The Inspector had opportunity to speak at length with the Manager/Proprietor and met her partner (the other registered provider). On the first day of the inspection there was a full day of interviews taking place for prospective staff members. The Manger had advertised through the job centre and had had a good response with the quality and quantity of applicants. The Inspector met with two members of staff and went through the staff records of three members of staff. The staff files are clearly laid out and contain the necessary information such as two written references, CRB check, terms and conditions, evidence of identity and so on. The recruitment procedure is clear. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 22 Supervision was taking place and being recorded. The induction process had taken place, but was ongoing for all the staff; currently the staff were holding their own induction records whilst completing the process. Staff were observed to engage sensitively with residents and had understanding of their needs. Staff rotas are displayed in the office; a fortnightly rota at present and previous rotas are stored in a file. There have been two meetings to date (18/9/06 and 2/10/06). These meetings have an agenda and minutes are recorded. The Proprietor and Manager both attended this meeting. The Manger was positive about the skills and expertise that staff members were bringing to the staff group as a whole. The staff group once established would benefit at the earliest opportunity on training for working with and managing challenging behaviour and also breakaway training. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well led home; there is an ethos of being open and transparent and improving the quality of residents lives. Records are of good standard. Improvements are needed around fire arrangements. EVIDENCE: The Registered Manager has been a qualified Social Worker for 10 years and an Approved Social Worker for several local authorities. Her first degree was in Management Studies. The Manager is due to undertake the Managers’ Award (RMA) in January 2007. The Manager presents as qualified, experienced and competent, particularly around mental health issues. She was open to learning from staff, service users, carers and other professionals, and gave considerable thought to meeting the needs of residents and promoting their rehabilitation and to improving the quality of life of residents. Resident felt that their views were listened to. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 24 Two requirements arose around fire procedures. A process needs to be in place to record every fire practice drill or test of fire equipment including fire alarm equipment, conducted in the care home and any action (as per Schedule 4) taken to remedy effects in the fire equipment. No fire drill had taken place with the residents involved and the testing of alarms emergency lighting etc. though taking place, were not being recorded. One fire drill had taken place but no residents were present and no record was made of this fire drill. The Manager was on the point of sending out an initial survey to service users, carers, relatives, referrers and professionals and setting up a suggestion box to raise issues for improvement. The Manager and staff team are alert to risks; for instance the knife drawer is locked. The refrigerator and freezer temperatures are checked twice daily and recorded. The water temperatures are checked weekly. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 3 X X 2 x Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA19 YA23 Regulation 13(1)(b) 13(b) Timescale for action Residents’ health checks must be 01/02/07 systematically recorded. The POVA policies/procedures for 01/02/07 the two referring authorities must be available in the care home. The extractor fan needs to 01/02/07 function in the downstairs bathroom. Fire drills must take place 01/02/07 regularly and be recorded. Testing of fire alarms, 01/02/07 emergency lighting must be recorded. Requirement 3. 4. 5. YA24 YA42 YA42 23(2)(b) 13(4)(c) 23(4) 13(4)(c) 23(4) 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 YA35 Good Practice Recommendations Update on working with and managing challenging behaviour for all staff members and breakaway training. Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Westside Home DS0000066707.V314940.R01.S.doc Version 5.2 Page 28 - 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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