Inspection on 15/11/05 for Westwood

This inspection was carried out on 15th November 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 16/11/07

Westwood 22/08/06

Westwood 19/07/05

Westwood 17/05/05

Westwood 02/02/05

Westwood 14/10/04

Westwood 03/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Westwood 284 Bath Road Worcester Worcestershire WR5 3ET Lead Inspector Y South Unannounced Inspection 15th November 2005 10.45 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 Westwood DS0000018697.V251212.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. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westwood Address 284 Bath Road Worcester Worcestershire WR5 3ET 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) 01905 353866 Mr Anthony Harold Downer Mrs Zinnat Esmail Downer Mr Anthony Harold Downer Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: Westwood is a modern bungalow with an extension at the rear. The home is situated on a main road out of Worcester City, conveniently sited for local amenities and transport. There is a small parking area at the front and a large attractive level garden at the back. There are eight single bedrooms six of which have en-suite facilities, and two double bedrooms one of which has an ensuite facility, communal toilets, bathrooms, dining room and three lounge areas. In addition there is a spacious furnished veranda opening onto the garden. Everywhere is well maintained and furnished in a comfortable homely manner. The registered owners, Mr and Mrs Downer, own and manage the home and offer a service for a maximum of twelve people of either sex over the age of sixty five years who have mild to moderate needs associated with old age. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over four and a quarter hours from 10.45am until 3pm. The registered proprietors assisted the inspector. She also spoke to two residents, one visitor and one member of staff. A partial tour of the building and a range of documents were seen. The focus of the inspection was on the requirements and recommendations that had been made following the previous inspection, and some of the key standards. A service questionnaire was sent to the home prior to this inspection and returned to the Commission for Social Care Inspection. The providers were also asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Seventeen responses were received and the answers to the questions were predominately positive. What the service does well: What has improved since the last inspection? Since the last inspection arrangements have been made to see and check prescriptions before they are taken to the pharmacist for dispensing. There has been an increase in the commitment to training and what has been achieved. Westwood DS0000018697.V251212.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. Westwood DS0000018697.V251212.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 Westwood DS0000018697.V251212.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): 1, 2, Written information is not available to assist people to make a decision on their choice of home. EVIDENCE: The Service Users’ Guide submitted with the services pre-inspection questionnaire did not contain all the elements listed in standard 1.2 and the copy of the Terms and Conditions did not contain all the elements listed in standard 2.2. A draft of the Statement of Purpose was seen earlier in the year. The finalised version was not seen during this inspection. Copies of all of these documents will need to be submitted to the Commission for Social Care Inspection when completed. It was recommended that the documents were initially simplified to contain the necessary legislative elements in order to avoid any omissions. They could then be developed further in accordance with the standards and providers’ wishes. Westwood DS0000018697.V251212.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): 8, 9, 10 Assessments of pressure care and nutritional needs are not sufficiently detailed to identify if a care plan is required to provide information and guidance for staff. The policies and procedures relating to medication do not fully protect service users. The facilities and philosophy of the home ensure service users are treated sensitively and their privacy is respected. EVIDENCE: A requirement had previously been made that detailed assessments needed to be undertaken in order to identify when care plans were needed for pressure care and nutritional care. These were still very superficial. Further guidance was given. The requirements will be repeated. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 10 A full inspection of medication management was undertaken by the Commission for Social Care Inspection pharmacy inspector on the 16th August 2005. Five requirements and two recommendations arose from this inspection Only two requirements had been met when compliance was assessed during this inspection. All timescales had expired. Procedures were still needed for the administration and recording of nonprescription homely medicines and the action to be taken in the event of a medication error. The date of opening of medication was recorded on containers to ensure a medication audit could be undertaken. However it was observed during this inspection that some eye drops in use were out of date. External medication needed to be physically separated and stored away from internal medication. As storage space was limited it was recommended that the cupboard be partitioned in order to meet the requirement. A controlled drugs cabinet was not available. Hand written MAR charts were not being checked by a second member of staff. It was observed that privacy and dignity was respected. Service users confirmed that they were treated with kindness and the provider confirmed that staff were instructed during induction on how to treat service users with respect at all times. There were two double rooms. Both were fitted with privacy curtains although only one room was double occupied. Westwood DS0000018697.V251212.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): 12, 13, 14,15 There is good interaction between the home and the community but a limited amount of stimulation available in the home. Service users are able to make choices relating to their routines. Good nutritional meals are provided for the people who live in the home. EVIDENCE: The providers described a range of activities that were available to the service users. These included a lady who visited for an hour every two weeks to undertake activities with the service users, musical entertainments, and a selection of library books, card games, scrabble, the garden and the television. There was no programme available and the provider said that the current service users were uninterested in most of the activities available with the exception of music and the radio. One service user said in the questionnaire that the activities provided were not always suitable and another person said that they were not suitable. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 12 The visitors’ book confirmed that service users received frequent visits. One service user was able to get out into the community independently and some people attended the church of their choice. The vicar came to the home each month. The care plan seen contained limited information regarding interests and activities. Although the majority of service users appeared happy with the current provision of activities is an area that could be developed further to provide a wider variety of stimulation and interest. Service users manage their own personal finances independently or with assistance from their family or legal advisers. The providers said that they held no money for service users. The records of meals provided indicated that a full and varied diet was provided. One of the providers had many years of experience in catering and undertook most of the cooking. The lunch served was appetising and plentiful. The service users ate with enjoyment. They confirmed that they enjoyed their meals. No special diets were currently required. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 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, 18 Some service users and relatives do not know how and with whom they can raise their concerns. Service users are protected from the risk of abuse by staff that receive training in its recognition. EVIDENCE: An acceptable complaints policy and procedure was seen. Before copies are inserted into the Statement of Purpose, Service Users’ Guide and Terms and Conditions of Residence the reference to the ‘NCSC’ must be replaced with the ‘Commission for Social Care Inspection’. Neither the home nor the Commission had received any complaints since the last inspection. It was noted the questionnaires indicated that three relatives and one service user were either unaware of the complaints procedure or would not know who they could raise their concerns with. It is recommended that relatives are given or sent a copy of the updated procedure and the service users’ attention is drawn to it when they are given their new copies of the Service Users Guide. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 14 A requirement was made in the previous inspection report that staff should receive training to recognise and respond to possible abusive actions. The provider said that five of the team of eight staff had received this training and he was seeking another course for the remaining three people. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 15 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, 26 The service users are provided with a comfortable home and facilities to meet their needs. EVIDENCE: A partial tour of the home was undertaken. It was observed to be clean and free from offensive odours. Decoration, furnishings and maintenance were of a good standard. The lock on one en-suite door was broken. The two shower rooms and one bathroom were all being used as storage which would need to be emptied before the service users could use them for their designated purpose. This is not acceptable. Better storage arrangements should be used. The provider said that they did not have a written programme of maintenance and renewal but they were aware of what improvements they wished to make and would undertake them when time and finances permitted. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 16 The laundry was situated in a separate building adjacent to the house. It was well equipped with a mixture of domestic and commercial appliances that met the sluicing and disinfection requirements. Although the walls and floor could be readily cleaned the room was untidy and in need of modernising. There was no liquid soap or disposable towels for staff use. It is acknowledged that difficulties relating to the inappropriate use of these items by current service users in communal areas has demonstrated a higher risk to them than that of cross infection. However this is not relevant in the laundry. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 17 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, 30 Implementation of an acceptable recruitment procedure ensures suitable staff are recruited to provide the care the service users need. Staff receive training to develop their knowledge and skills in providing acceptable care. EVIDENCE: The home has a very small work force with no staff designated solely for domestic or catering duties. The roster indicated that three people were rostered on duty each day and at night there was one awake and one or two asleep. Sleeping in duties were undertaken by the proprietors. The questionnaires and service users confirmed that their care needs were being met. Three of the eight staff were qualified in NVQ or the equivalent. Consideration should be given as to how this number can be increased. Standard 28 requires that 50 of the team should be qualified to level 2 or above by the end of this year. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 18 One person had been appointed to the team since the previous inspection. Her records were checked and found acceptable. The training analysis and information provided indicated that training was being undertaken. The providers were pleased with the commitment shown by some of the staff. Core training subjects include fire safety, first aid, food hygiene, health and safety, moving and handling and Protection of Vulnerable Adults. The home has made good progress to ensure all staff receive current training in these areas. If the commitment and motivation continues all team will soon be up to date. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 19 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): 35, 37, 38 Service users’ financial interests are safeguarded by the policies of the home. However written information is not available to inform current and prospective service users of the home, service offered and agreed, and the home is not operating within its categories of registration. The home is operating in a manner that protects the safety of people but some policies and procedures are needed to inform and guide staff in aspects of their work. EVIDENCE: As previously stated it is the home’ policy not to be involved with service users’ personal finances. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 20 It was recommended that, to safeguard the home and personnel, an addition be made to the information provided to staff, residents and visitors that staff are not permitted to accept gifts or bequests, neither are they permitted to assist in the making of service users’ wills. The service’s pre-inspection questionnaire indicated that policies and procedures were needed relating to • Aggression by service users to staff, • The control of substances hazardous to health, • The disposal of clinical waste, • The death of a service user, • Pressure care assessment and care, • Racial harassment The pre inspection questionnaire indicated that two service users suffered from dementia and one person had mental health needs. This was confirmed by the providers during the inspection. The registered providers were informed that their categories of registration did not include these needs and were advised to write immediately to the Commission for Social Care Inspection and apply for a variation in the conditions of their registration. The fire log was assessed. Fire safety checks and training were being undertaken. The equipment and services in the home were being appropriately monitored and maintained. No obvious hazards were observed. Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 21 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 1 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X 2 3 Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 22 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 OP1 Standard Regulation 4, Requirement A Statement of Purpose that contains all the information listed in Schedule 1 of the Regulations must be available. A copy must be provided to the Commission for Social Care Inspection before the timescale expires. The home must operate within its categories of registration. Therefore an application must be made to vary the conditions of registration to include places for one named person with mental health needs and two named people with dementia care needs. A Service Users’ Guide containing all elements listed in standard 1.2 must be given to each service user and a copy sent to the Commission for Social Care Inspection before the timescale expires. Timescale for action 01/02/06 2 OP1 4 15/11/05 3 OP1 5 01/02/06 Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 23 4 OP2 5 The Contract/Terms and Conditions of Residence must contain all the elements listed in standard 2.2, and be provided for every service user when they are admitted to the home. A blank copy must be sent to the Commission for Social Care Inspection before the timescale expires. Service users must be assessed in order to identify those who have developed or are at risk of developing pressure sores in order that a care plan can be devised instructing staff how the specific needs will be met. Nutritional assessments must be undertaken on admission and on a periodic basis to ascertain if there are any needs that should be addressed through a care plan. A procedure for the administration and recording of non-prescription homely medicines must be developed by the care home. The use of eye drops must be discontinued once month after the container has been opened. External medication must be physically separated and stored away from internal medication. The medication policy should be reviewed and include a procedure to follow in the event of a medication error. 01/02/06 5 OP8 12, 13 01/02/06 6 OP8 14 01/02/06 7 OP9 13(2) 01/02/06 8 OP9 13(2) 15/11/05 9 OP9 13(2) 01/02/05 10 OP9 13(2) 01/02/06 Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 24 11 OP19 13 The lock on one en-suite door must be repaired and the extraneous articles removed from the service users’ shower and bathrooms. Liquid soap and disposable towels must be readily available in the laundry. 01/02/06 12 OP26 13, 16 15/11/05 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 OP9 Good Practice Recommendations Hand written MAR charts should be checked and signed by two members of staff. A controlled drugs cabinet, which meets The misuse of Drugs (Safe Custody) Regulations 1973 should be obtained in the event that a Controlled Drug has to be stored in the home. It is recommended that efforts be made to identify and expand a range of in house activities that interest the service users. It is recommended that action is taken to ensure residents and visitors are aware of the complaints’ procedure. A full range of policies and procedures should be available to inform and guide staff in their duties. It is recommended that staff, residents and visitors are informed that staff are not permitted to receive gifts or bequests or assist service users to make their wills. 3 4 5 6 OP12 OP16 OP37 OP18 Westwood DS0000018697.V251212.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 DS0000018697.V251212.R01.S.doc Version 5.0 Page 26 - 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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