Inspection on 07/12/05 for Westwolds Care Centre

This inspection was carried out on 7th December 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westwolds Care Centre 30/09/08

Westwolds Care Centre 31/10/06

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 Unannounced Inspection 7th December 2005 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.V266906.R01.S.doc Version 5.0 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.V266906.R01.S.doc Version 5.0 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.V266906.R01.S.doc Version 5.0 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. 12th July 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 one double, currently being shared by a couple. 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 care park to the front of the building. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection 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. Four service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those service users spoken with were happy with the care received and the standards within the home. The manager assisted in the inspection process and three other members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and promoted a caring atmosphere. What the service does well: What has improved since the last inspection? First aid training has been researched however has yet to be booked Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 6 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.V266906.R01.S.doc Version 5.0 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.V266906.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed during this inspection. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 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): 7,9,10 Individual plans of care are in place reflecting needs, choices and preferences however this may be compromised when initially entering the home due to delays in this process. Service users are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Four service users plans of care were observed, two of which were recent admissions to the home. Service users undergo various assessments with regards to the activities of daily living, manual handling, falls, nutrition and mental health, information gained forms the basis of the plan of care. Care plans in place were personalised and addressed preferences, choices and needs with the exception of one where following the assessment a plan of care and risk assessments had not been put into place. The manager stated this was due to the care manager being on annual leave. A review had been undertaken and reflected care needs were being met despite this. Within all other care plans relevant risk assessments and management was in place. There was evidence that service users and relatives are given the opportunity to be involved in the care planning process. There was also evidence of the Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 10 multidisciplinary team being liaised with and relevant equipment and aids in place. Daily records were maintained and significant events were noted. Medications checked on the day of inspection were satisfactory and relevant policies and procedures were in place and adhered to. Staff were advised to liaise with service users general practitioners with regards to the monitoring of vital statistics and the administration of the medication digoxin. All staff undergo a through induction programme which incorporates resident welfare training and maintaining privacy and dignity of service users. Evidence of this was available within staff personnel files observed. Visitors may be received in private in service users rooms or the television lounge, service users spoken with stated that visitors are always made welcome and a flexible routine was facilitated with regards to how they choose to spend their day. 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, which one service user substantiated. Service users spoken with expressed that staff were kind and respectful and maintained privacy at all times. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 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): 15 Service users receive a wholesome, appealing balanced diet in pleasing surroundings, however safety may be compromised due to the lack of documentary evidence supporting cleaning within the kitchen is taking place. EVIDENCE: A four weekly menu is followed which demonstrated a wholesome and appealing diet is on offer. Choices and alternatives are available and service users substantiated that this was offered and food was at a good standard and 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. The catering is contracted out and staff are supplied by an agency. On observation of the kitchen relevant equipment was in place and it was noted to be clean and tidy. Records observed were satisfactory with the exception of the cleaning records were several gaps were noted. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users are protected from abuse. EVIDENCE: 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.V266906.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: Not assessed during this inspection. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 14 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 Service users are in safe hands at all times and the numbers and skill mix of staff meets their needs. Service users are supported and protected by the homes recruitment policy and procedures. EVIDENCE: The duty rota was observed and demonstrated sufficient staff are employed to meet service users current needs. Four staff have attained the national vocational qualification in care level two one has attained level three and six are working towards level 2. All staff undergo a thorough induction at a recognised standard, evidence of which was available in service users personnel files. Staff spoken with stated that training was at a good level and they felt supported in their job role. Four staff personnel files were observed which contained all the relevant documentation with regards to schedule two of the care standards act. Staff substantiated they had had criminal records bureau checks. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 15 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): 31,33,38 Service users live in a home which is well run in their best interest and managed by a person who is fit to be in charge, of good character and able to discharge her responsibilities fully. The health, safety and welfare of service users and staff are promoted and protected however may be compromised due to further fire drill training required. EVIDENCE: The manager has worked at Westwolds for twenty-four years during which time she has attained relevant knowledge and skills for her to carry out her current position. She is currently working towards 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. She expressed she felt supported and was aware of the networks in place to enable this. Staff spoken with expressed the manager was Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 16 approachable and listened to suggestions and concerns; service users stated 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. She is currently in the process of devising a questionnaire for the multidisciplinary team so as to gain additional feedback. 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 regional manager visits the home on a monthly basis and completes a regulation 26-feedback form. There was evidence of reviews in service users plans of care to ascertain whether needs are met, relatives have been involved in these processes on occasion. Comment cards are available in the main entrance should a service user or visitor wish to complete them. Maintenance and servicing certificates 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. Appropriate risk assessments are in place. The fire log book was observed and was satisfactory with the exception of staff attending fire drills, 19 staff out of 28 had attended a fire drill in the last year, however on speaking with staff they could not recall the last drill, they did however substantiate they had attended a fire lecture and that they felt confident they would act accordingly in the event of a fire. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement All service users admitted into the home are required to have a plan of care and relevant risk assessments in place to ensure all care needs are met. The manager is required to liaise with the contacting agency to ensure appropriate records with regards to the cleaning of the kitchen are maintained. The responsible individual is required to make suitable arrangements for the training of staff in first aid. This has been research but now needs addressing to fully comply with this requirement. All staff are required to complete fire drill training to ensure the health, safety and welfare of service users. Timescale for action 07/01/06 2 OP15 23(2,d) 07/01/06 3 OP30 13(4,c) 07/01/06 4 OP38 23(4,c,iii) 07/01/06 Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 Page 19 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 Staff are to liaise with service users general practioner with regards to the monitoring of vital statistics and the administration of medicines. Westwolds Care Centre DS0000008774.V266906.R01.S.doc Version 5.0 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. 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