Inspection on 14/07/05 for Westwood

This inspection was carried out on 14th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Westwood 17/03/07

Westwood 13/01/06

Westwood 01/12/04

Westwood 05/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Westwood 55 St Helens Park Road Hastings East Sussex TN34 2JJ Lead Inspector Jo Mohammed Unannounced 14th July 2005 1:45pm 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 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 Stationary 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. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westwood Address 55 St Helens Park Road Hastings East Sussex TN34 2JJ 01424 428805 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hastings & Bexhill Mencap Society Mrs Joanne Wilson Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is nine (9). 2. The people accommodated will be between the age of eighteen (18) and sixty-five (65) years on admission. 3. The home can continue to provide care and accommodation to a service user who was admitted over the age of sixty-five years on admission. Date of last inspection 01 December 2004 Brief Description of the Service: Westwood is a large two-storey detached property situated in a residential area of Hastings. Shops and transport links are close by. The home is registered to provide care and accommodation to nine people with Learning Disabilities. All service users have single bedrooms. There are currently no vacancies. The registered providers are Hastings & Bexhill Mencap Society. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between 1.45pm and 5.15pm. A total of 18 standards including 14 out of the 19 key standards were inspected. All the service users were at home on the day of the inspection. Seven were spoken too on an individual basis. A tour of part of the premises took place and discussions were had with the Manager. Time was also spent examining records. What the service does well: What has improved since the last inspection? There were five requirements and three recommendations identified at the last inspection. Since then two requirements and two recommendations have been fully achieved. Very good progress has been made in terms of establishing a quality assurance programme whereby the views of service users living in the home and relatives have been sought through the implementation of questionnaires and action is currently being taken address the findings from this survey. More staff are either working towards a National Vocational Qualification in care or will be soon. Some fire safety matters identified at the last inspection have been addressed and a planned maintenance and renewal programme for the fabric and decoration of the building has been devised. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 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. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 8 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 standard(s) EVIDENCE: There have been no new admissions to the home since the last inspection so it was not possible to assess current admission practices and procedures. This key standard 2 will be inspected at future inspections should a new service user move into the home. It is known from a previous inspection that the last service user admitted to the home had a full assessment completed prior to admission. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6,7,9 The home is good at enabling service users to be involved in the planning of their care so that they can make decisions and choices in order to achieve greater empowerment and autonomy. EVIDENCE: All service users have individual plans of care that identify goals and action plans, a personal planning book, assessment and profile details, a record of likes and dislikes and other key data. Two service users files were examined. It was evident these plans of care are drawn up with service users’ involvement and reviewed regularly. It was recommended that the information contained in service users personal planning books be dated, fully completed and that action plans drawn up correspond with service users assessment information. All service users have a designated key-worker. It was evident through conversations with service users that they are encouraged to make their own decisions, choices and be as independent as possible. There was also evidence in service users care documentation that any restrictions on choice are recorded. Joint meetings between service users and staff regularly occur and a meeting of this kind was taking place at the time of the inspection. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 10 It was said that three service users attend advocacy meetings and advocacy services are to be sought for one service user. All service users have risk assessments in place, encouraging them to live as independently as possible. These were seen to be reviewed and updated on a regular basis. A written procedure for dealing with unexplained absences/ missing persons has been compiled and since the last inspection the contact details about notifying the CSCI has been added to this documentation. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12,13,14,15. Good links with the community, attendance at educational centres and work opportunities take place as well as service users maintaining contact with relatives. Choice and consultation in following these activities was evident so as to enrich service users lifestyles. EVIDENCE: Service users spoken too explained the type of educational, training and work activities they attended during the week ranging from going to different day centres, undertaking voluntary work and attending college courses. Two service users independently go swimming three times a week as well as accessing community activities. Service users spoke about how they participated in the local community and pursued leisure interests such as going to the local church, shopping, cinema, pub, walks, social events, gardening, writing, photography, watching Television and participating in the Special Olympics. They also advised they were going on holiday to the Isle Of Wight later in the year. Service users are supported to maintain contact with family and friends through visits, correspondence and telephone calls and this was confirmed when speaking to service users. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 20 The systems for administration and dispensing of service users medication has improved with on-going attention being given in order to comply with the recommendations made by the CSCI pharmacist to ensure safe practices are followed. EVIDENCE: One service user self-administers topical medication. A risk assessment for this practice is in place and a record kept of prescribed medication. From the information supplied records relating to the administration and dispensing of medication was found to be in order and stored safely and securely. Following a previous inspection a Pharmacist from the CSCI visited the home due to a drug error and wrote a list of recommendations for the home to follow through. The home has practically achieved meeting these points that included updating their medication policies and procedures. The only matter that remains to be met is to introduce on-going competency training for staff in medicine practices and procedures. The Manager advised this is to commence this year. A local Pharmacist visits the home every three months. With the exception of one new staff, the remaining staff team have completed a training course in ‘Care of Medicines’ that was reported to be accredited. It was agreed that training for one staff member would be arranged. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22,23 The home has satisfactory adult protection and complaints policies and procedures in place and service users know who to contact if they have a complaint. It is important that training for all staff in adult abuse is provided so as to safeguard service users from abuse. EVIDENCE: The home has a complaints policy and procedure and there was evidence to show service users and relatives had been given a copy of this. It was discussed that a different format for some service users may have to be introduced to ensure it is fully understood. Following examination of the complaints log, no complaints have been received since August 2003. Service users spoken too said that if they were unhappy they would speak to staff. An adult protection policy and procedure was available including a copy of the local multi-agency guidelines. Since the last inspection the home has obtained a copy of [POVA] the Prevention of Vulnerable Adults guidelines. A copy of the Whistle-blowing policy was not found and the Manager agreed to ensure a copy was available in the home. Since the last inspection an adult protection matter has been concluded. It was reported by the Manager that three staff so far have received training in adult abuse. The remaining staff team must also receive this training. A policy and procedure for the management of service users monies was available. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24,30 The general standard of décor was satisfactory providing service users with a comfortable and homely environment. EVIDENCE: A partial inspection of the home was carried out and on the whole it was found to be comfortable, clean and satisfactorily maintained. It was drawn to the Manager’s attention a musty odour in two service users bedroom located on the ground floor that requires monitoring as well arranging for the inner walls near a ground floor bathroom to be looked at that had bubbled patches. Since the last inspection a planned maintenance and renewal programme for the fabric and decoration of the premises has been compiled. Also completed is the side driveway that has been tarmaced and is to be used as an additional garden area for service users once new a lawn has been laid. The laundry room is located outside in the garage. This was found to be satisfactory in appearance with adequate equipment and hand-washing facilities in place. Infection control policies and procedures were not found and these should be compiled. As discussed at previous inspections the home continue to keep under review service users and staff accessing the laundry room in adverse weather conditions. Risk assessments for safe working practices are in place and it was evident these had been reviewed. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35 The majority of staff are working towards NVQ qualifications so that service users are supported by a trained staff team. It is important that a staff training and development plan is devised so that staffs training needs can be addressed EVIDENCE: It was reported that one member of staff has completed their NVQ level 2 in care; one person is to complete the same in September 2005. One member of staff is currently working towards this qualification and two staff are to be enrolled to start this training in September. The home is aware that 50 of care staff [including agency staff] achieve an NVQ 2 in care by 2005. Two requirements made at the last inspection relating to recruitment were discussed and a staff file examined. It is known that no new staff have been employed since the last inspection, however there is a need for the home to obtain evidence that current staff are physically and mentally fit for the purposes of the work to be performed and obtain proof of staffs’ identity. It was said this would be followed through for any new staff. Staff files examined contained individual checklists showing training that staff have completed to date. There is no overall training and development plan and this should be compiled. Induction training for new staff is undertaken. There was evidence to show a structured format to do this was in place. The home should check to make sure this meets Sector Skills Council specification. Mandatory and some core training topics for staff was discussed. There is a need for the home to ensure that all staff receive regular training in manual handling and first aid, as there are some gaps in staff being trained in these areas. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,42 The Manager is experienced, competent and provides good leadership to ensure the home is effectively run. A good system in respect of seeking the views of service users and relatives as part of the home’s Quality Assurance policy has been implemented since the last inspection. Seeking the views of other interested parties as well will further benefit the home when reviewing its performance. Health and safety practices are satisfactory. Some attention to staffs training requirements is needed. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 17 EVIDENCE: It was not possible to fully assess standard 37, as it is not clear if the Manager has obtained a care qualification alongside their completed NVQ level 4 in management. Identified at the last inspection was for the Manager to make further enquiries in clarifying this matter and inform the CSCI. The Manager demonstrates competency and experience in running the home. It was evident that an open, positive and inclusive atmosphere in the running of the home was in place with good leadership. Service users expressed complimentary remarks about the staff team and management of the home. Since the last inspection pictorial quality assurance satisfaction questionnaires in respect of seeking the views of service users have been devised and completed and similar questionnaires completed by relatives. This information has been collated and action is currently being taken by the home to act on these findings to assist in reviewing its performance. It was recommended that these questionnaires be dated and extended out to seek the views of other interested parties such as advocates and healthcare professionals. The home has a range of generic risk assessments in place as well as individual ones for service users that are regularly reviewed. Fire records, fire drills, training in fire safety and a current fire risk assessment were found to be in order. The Manager is to arrange for staff where necessary to receive refresher training in moving/manual handling and First Aid, further details about this is recorded under the staffing heading in this report. The accident book, a selection of health and safety records relating to maintenance and checking of equipment was examined and found to be in order. Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 2 x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westwood Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 19 yes 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. 3. 4. Standard 23 30 32 34 Regulation 13 [6] 13 [3] 18 [1] [a] [c] 19 [1] schedule 2 Requirement That all staff must receive training in adult abuse. Timescale for action 30th September 2005 30th September 2005 By 2005 5. 6. 35 35 & 42 18 [1] 18 [1] [c] That infection control policies and procedures must be compiled. That 50 of care staff [including agency staff] achieve a care NVQ 2.[previous requirement] The home must obtain evidence Immediate that staff are physically and mentally fit for the purposes of the work to be performed at the home.[Previous timescale of 31st May 2004 not met]Obtain proof of staffs identity.[Previous timescale of 1st Decemer 2004 not met] A training and development plan 30th must be compiled. september 2005 All staff must receive regular 30th training in manual handling and September first aid. 2005 Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 37 Good Practice Recommendations The Manager should clarify whether the care qualification held meets the standards and inform the CSCI in writing.[Previous timescale 1st December 2004 not met] Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Westwood H59-H10 S21283 Westwood V217778 290605 Stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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