Inspection on 31/10/06 for Westwolds Care Centre

This inspection was carried out on 31st October 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

Westwolds Care Centre 30/09/08

Westwolds Care Centre 07/12/05

Westwolds Care Centre 12/07/05

Westwolds Care Centre 17/03/05

Westwolds Care Centre 23/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westwolds Care Centre 4 Park Avenue Burton Joyce Nottingham NG14 5AF Lead Inspector Karmon Hawley Key Unannounced Inspection 31st October 2006 10:00 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 Westwolds Care Centre DS0000008774.V309764.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. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwolds Care Centre Address 4 Park Avenue Burton Joyce Nottingham NG14 5AF 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) 0115 9313659 0115 9313769 the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Mrs Elizabeth J. Fletcher Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named individual with dementia. The service user’s needs are to be reviewed six monthly with the social worker to ensure that the care staff are still able to meet the needs and that other service users are not being put at risk. When the service user’s contract is terminated for any reason the registration returns to its pre-existing state. 7th December 2005 Date of last inspection Brief Description of the Service: Westwolds is a purpose built single storey home set in the quiet village of Burton Joyce. It can offer accommodation for up to 33 older people within the category of old age only. A variation for registration has been agreed for one named service user with Dementia to be admitted to the home. There are two service users below 65 who have lived there for a number of years; the certificate does not reflect this, however a variation has been applied for. The accommodation is in single rooms with the exception of two doubles, currently being shared by married couples. All but six of the rooms have ensuite facilities; fourteen rooms have kitchenettes to enable independent living for those service users who are able. The centre of the village is a short walk away and provides access to shops, churches, public houses, a coffee shop and a supermarket. Service users can access public transport in the village, although there is a mini bus available, which belongs to the home. There is a very pleasant inner courtyard garden and a car park to the front of the building. The current weekly fees range from £329 - £345 the manager said that the price is dependant upon room size and top up fees may be charged as required following negotiation. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. The unannounced site visit took place in four and a half hours and was performed by one inspector. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with and one relative, so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? Staff have attended first aid training and updated in other mandatory areas ensuring service users are further protected. All new service users admitted to the home have plans of care in place ensuring their needs are fully met. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 6 Further staff have undertaken fire drills, however it is recommended that the remaining staff complete this. New documentation has been introduced in the kitchen, which ensures that all records are maintained therefore further protecting service users. Further in depth quality assurance monitoring has been introduced ensuring the service is run in the best interest of service users and a quality service is provided. 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. Westwolds Care Centre DS0000008774.V309764.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 Westwolds Care Centre DS0000008774.V309764.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to admission. The home does not offer intermediate care. EVIDENCE: The manager visits prospective service users prior to being admitted to the home and carries a preadmission assessment. The assessment covers the requirements of the standard and evidence was available to demonstrate necessary equipment and adaptations are obtained prior to admission. Prospective service users may also visit the home and spend time prior to making a decision to live there. The home does not offer intermediate services. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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): 7,8,9 and 10 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in an individual plan of care, however further development of risk assessments is required. Service users health care needs are fully met. Service users are protected by the homes polices and procedures for dealing with medicines, however it is recommended that further plans are put into place for temperature control during hot spells of weather. Service users feel that are treated with respect and their right to privacy is upheld. EVIDENCE: Four service users case files were seen. Service users undergo various assessments such as the activities of daily living, nutrition, falls, pressure area care and dependency. Information gained forms the plan of care. Care plans addressed highlighted needs and were extremely personalised and individualised. Due to the change of documentation the manager said that risk assessments were still in the process of being completed and developed in the files seen, however risks had been identified within the plan of care and Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 10 instructions given to management the risk. There was evidence of service user involvement and that choices and preferences are taken into account. Reviews take place monthly to ensure service users are satisfied with care received. Daily records were maintained as required and recorded significant events. Service users spoken with said that staff helped them as needed and that their needs were fully met. Appropriate specialist services are accessed such as the dentist; optician and tissue viability nurse to ensure health care needs are met, there was evidence seen within care plans to show this takes place. These services are offered within the home and also within the community. Service users are facilitated to access these and there is a mini bus available to assist this process. Two service users spoken with said they could see the doctor when they wish. Relevant policies and procedures for dealing with medicines were in place. The home had recently had a visit from the pharmacist who supplies the medicines to the home, a few minor recommendations were made, and the manager said these are being addressed. Medications records and prescriptions were checked, these corresponded and clear records of administration were available. The manager had liaised with the doctor about the monitoring of vital statistic when service users are on certain medicines, this was not deemed necessary. During the summer months the room temperature had exceeded the recommended, the manager said that certain medicines had been placed in the fridge during these times; this was recorded. All staff undergo a through induction programme which includes maintaining privacy and dignity of service users. All consultations are carried out in private. There is a telephone available for service users to use and some service users have their own private line. Service users spoken with expressed that staff were kind and respectful and maintained privacy at all times. Staff spoken with were able to discuss how they ensure privacy and dignity is maintained when assisting service users. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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 The quality rating for this outcome area is excellent. This judgement was made using evidence available including a visit to the service. Service users find the lifestyle experienced in the home matches their expectations and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings. EVIDENCE: There was evidence within plans of care that service users expectations, preferences and capabilities are documented and considered. On speaking with service users they said that they were happy living in the home and they can choose how they spend the day. They said that staff were kind and considerate and assisted them as needed. All service users spoken with said that choices were available and they felt that staff listened to them and respected them as individuals. There was evidence seen that a good relationship is maintained between staff and service users. There is an activities coordinator employed and activities are offered should a service user wish to participate. Activities on offer were seen to be wide ranging and planned to meet individual needs. Service users spoken with said that they enjoyed activities as arranged. Staff spoken with expressed that individual needs are taken into account and more Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 12 diverse activities are now on offer, such as visits to the cinema and swimming pool. One service user spoken with discussed their recent trip to the theatre. A local vicar visits the home to provide Holy Communion to those who require it. There are no restrictions on visiting and service users can choose who they see and where they see them. One relative spoken with spoke highly of staff and the standards of care. There was evidence of a good rapport between service users, relatives and staff. Service users are facilitated to attend functions within the community. Service users are encouraged to bring in personal possessions and service users rooms were extremely personalised. Staff were able to discuss how they ensure that service users rights and choices are maintained and individual care is offered. Service users spoken with said that staff treated them as individuals and they may make choices as they wish. A four weekly menu is followed which showed that a wholesome and appealing diet is on offer. Choices and alternatives are available and service users confirmed that this was offered, food was at a good standard and was plentiful. Specialist diets are catered for and these were noted in the plan of care. Staff assisted service users during the main meal appropriately. Some service users have kitchen facilities in the flats, staff assist in recording temperatures for fridges if required and if able some service users prepare their own breakfast. Staff employed by the service now provides the catering service. On observation of the kitchen relevant equipment was in place and it was noted to be clean and tidy. Records such as cleaning rotas and food temperatures were observed and were maintained as required. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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): 16 and 18 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users and their relatives may be assured that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Relevant policies and procedures for dealing with complaints were in place. There have been no complaints received since the previous inspection. The manager states she has an open door policy, and is available to meet service users and relatives on a formal basis once a month. Evidence of a good relationship with service users and relatives was seen during the inspection. Service users spoken with stated they had no complaints but if they were unhappy they felt that they could discuss any issues with staff and these would be dealt with. Staff were able to discuss how they would deal with any complaints should they receive them. Relevant policies and procedures are in place with regards to adult protection and staff were able to discuss these issues appropriately. All staff have criminal records bureau checks in place. Personal allowances are kept on the premises; individual records are maintained for these. There are policies with regards to accepting gifts and wills. Service users spoken with spoke highly of care delivered and the staff and no complaints were voiced. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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 quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: Relevant maintenance records were seen which showed that maintenance takes place on a regular basis. The maintenance person has continued to redecorate the environment as required. There are specialist adaptations and facilities available. The grounds are well kept and there is a large garden to the rear. The home is wheelchair accessible. The environmental health officer has recently visited the home, no requirement were made. The fire officer has also recently visited the home and one recommendation was made for moving a fire extinguisher, the manager said this had been done. The premises were clean and hygienic and systems are in place for the prevention of the spread of infection. Staff spoken with were able to discuss the policies and procedures. The washing machine has a sluicing facility and designated areas for clean and dirty linen. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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): 27,28,29 and 30 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. The numbers and skill mix of staff meets service users needs. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policies and practices. Staff are working towards ensuring they are fully trained and competent to do their jobs. EVIDENCE: The duty rota was observed and demonstrated sufficient staff are employed to meet service users current needs. Staff spoken with said that there are enough staff available. Service users spoken with said that staff were available when needed to assist them. Fifty percent of staff have attained or are working towards the National Vocational Qualification in care level two (a nationally recognised work and theory based qualification) one member of staff has attained level three. All staff undergo a thorough induction at a recognised standard, evidence of which was available in service users personnel files. Four staff personnel files were observed which contained all the relevant documentation. Staff spoken with said that they had had criminal records bureau checks. Staff training records seen showed that staff are working towards completing all areas of mandatory training. There was evidence also seen to show that further training has been arranged. Staff spoken with stated that training was at a good level and they felt supported in their job role. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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): 31,33,35 and 38 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. 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 their responsibilities. Service users live in a home that is run in the best interests of service users. Service users personal financial interests are safeguarded. The health safety and welfare of service users and staff are promoted and protected, however it is recommended that further staff members undertake fire drills. EVIDENCE: The manager has worked at Westwolds for twenty-five years during which time she has attained relevant knowledge and skills for her to carry out her current position. She has now achieved the Registered Managers Award and has completed a City in Guilds advanced care management course. She remains up to date with all mandatory training and training appropriate to her job role. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 17 Staff spoken with said the manager was approachable and listened to suggestions and concerns. Service users said they were well looked after and the home was well run. The manager stated the Commission for Social Care Inspection annual questionnaires are sent out to service users. Monthly audits are carried out which cover all aspects of the home, facilities and services. Results are sent to head office and action plans devised as required to address any issues. The recent results of a survey for the food provided were seen, the outcomes being of a positive nature. Four service users personal allowances were checked. These corresponded with the accounting sheet. Receipts are kept for all transactions and two staff sign for these. The manager is not responsible for anyone’s money. Maintenance and servicing certificates such as gas and electric appliances were observed and were satisfactory. Accident books contained required information and statistic are sent to head office on a monthly basis to audit accidents occurring. The fire logbook was observed and was satisfactory 24 staff have now attended a fire drill; nine staff have still to complete this. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4,c) Requirement Continue to develop risk assessments and ensure appropriate management plans are in place to ensure service users are fully protected. Timescale for action 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP38 Good Practice Recommendations To continue to monitor the drug room temperature and ensure contingency plans are in place should this exceed the recommended temperature. All staff complete fire drill training to ensure the health, safety and welfare of service users. Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Westwolds Care Centre DS0000008774.V309764.R01.S.doc Version 5.2 Page 21 - 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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