Inspection on 17/05/05 for Westwood

This inspection was carried out on 17th May 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

Westwood 16/11/07

Westwood 22/08/06

Westwood 15/11/05

Westwood 19/07/05

Westwood 02/02/05

Westwood 14/10/04

Westwood 03/03/04

Similar services:

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 Yvonne South Unannounced Inspection 17th May 2005 10:10am 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 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 E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westwood Address 284 Bath Road Worcester WR5 3ET 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) 01905 353866 Mr Anthony Harold Downer Mrs Zinnat Esmail Downer Mr Anthony Harold Downer Care Home 12 Category(ies) of OP Old Age - 12 registration, with number of places Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no further conditions of registration to those recorded on the previous page. Date of last inspection 2 February 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 ensuite facilities, 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 providing care for a maximum of twelve people of either sex over the age of sixty five years. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first routine unannounced inspection to be undertaken during the year from 1st April 2005 until 31st March 2006. However when the inspector arrived a Fire Safety Training session was in progress from an external trainer. The owners and all the staff were attending. As it was inappropriate for anyone to leave the training session to assist the inspector she asked for and examined two sets of service users’ care plans, two sets of staff files and spoke to four service users. After one hour she left the home having toured the premises, and undertook to return in the near future to undertake a full inspection and check compliance with the requirements that had been set following previous inspections. These were not checked on this occasion and have therefore been repeated unchanged in this report. What the service does well: What has improved since the last inspection? This could not be assessed, as the full inspection did not take place. Westwood E52 S18697 Westwood V224927 170505.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 E52 S18697 Westwood V224927 170505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 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 standard(s) These standards were not assessed during this visit. EVIDENCE: Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 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 standard(s) These standards were not assessed in full. Insufficient up to date information was available to guide and instruct staff in providing individual care. EVIDENCE: The inspector asked to see the care plans for one dependent service user and one other. The documents that were provided were headed ‘Assessments’. They contained limited information and lacked any guidance relating to oral and foot care. There was no indication that service users had been involved in their compilation or that they had been reviewed monthly as is required. However Mrs Downer confirmed that some reviews had taken place. Good continence management guidance was available and good information regarding interests, activities and family/community links. Some documents had not been signed and dated when compiled. The service users were most complimentary regarding the care they received. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 10 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 standard(s) These standards were not assessed in full. A range of in house activities was provided for the service users. Visitors were welcomed. EVIDENCE: The records that were seen contained good information regarding the person’s interests, family and community links. Service users confirmed that they received visitors and were able to go out if and when they chose. They enjoyed the garden, watching the television and listening to the radio and story tapes. Two people were reading and there was a good supply of literature. A service user said that in the past there had been a group of service users who enjoyed playing cards. People came and went and she was hopeful that such an activity could be repeated in the future. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 11 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 standard(s) These standards were not assessed in full. Service users knew how and to whom they should take their complaints. EVIDENCE: Service users said that they had no complaints and they were aware of the action they should take if they had any concerns. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 12 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 standard(s) These standards were not assessed in full. Service users lived in a comfortable environment with facilities provided to meet their needs. EVIDENCE: A brief tour of the premises was undertaken. It was seen that the décor and building were well maintained, attractively decorated and furnished with the exception of one bedroom doorframe where the paint was peeling. An upholsterer was in the process of recovering the dining room chairs at the time of the visit. Service users were happy for the inspector to see their rooms, which they described as ’lovely’. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed in full. The recruitment procedure does not protect vulnerable people. EVIDENCE: Two staff files were inspected. Both contained an application form, one lacked a second reference, neither had a personal photograph, CRB or POVA check. Mr Downer said that they had applied to join an umbrella body through which CRB and POVA checks would be obtained. Until their application had been approved their checks could not be undertaken. It is unacceptable and unsafe for staff to be appointed and commence their duties before these checks had been undertaken. The staff and the registered persons were undertaking fire safety training at the time of the inspection. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not addressed during this visit. EVIDENCE: Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 16 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. Standard 1 Regulation 4 Requirement The person registered must ensure that the Statement of Purpose is amended, so that it includes all the information detailed in Regulation 4 and Schedule 1 (Care Homes Regulations 2001). (Requirement originated from inspection 14/10/04.) The person registered must ensure a Service Users Guide, which includes all the information detailed in Regulation 5 (Care Home Regulations 2001) and National Minimum Standard 1 must be available in the home. Copies must be given to all current and prospective service users. Timescale for action 1st May 2005 2. 1 5 1st May 2005 3. 3, 37 14 (Requirement originated from inspection 14/10/04) The person registered must With ensure a written assessment is Immediate completed before the admission effect of any service user in accordance with the requirements of Regulation 14 (Care Homes Regulations 2001) and National Minimum Standard 3.3. E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 17 Westwood 4. 7 15 5. 7, 37 12(1), 15(1) 6. 7, 37 13(5) 7. 8 12(1), 15(1) 8. 9, 37 13(2) 9. 18, 30 12(1), 13(6) The person registered must ensure all service users care plans are reviewed at least once a month. The person registered must ensure that all sevice users have care plans in place, which accurately reflect their current care needs and the care to be provided by staff to meet those needs. All documentation should be signed and dated on completion by the person responsible. The person registered must ensure that moving and handling assessments are complete for each service user, which identify any needs and detail any aids/equipment or physical assistance, which may be necessary. Systems should be in place which ensure assessments are updated to reflect any changes in the service users well being. The person registered must ensure all service users are screened for the risk of developing pressure sores. Care plans must be initiated whenever risks are identified, which detail the action to be taken by staff to eliminate any risk. The person registered must ensure that staff sign and date any amendments or additions they make to medication charts. The person registered must ensure that all staff receive training on abuse and the protection of service users. Training should also be provided to raise staff awareness of local vulnerable adults protocols and With immediate effect. With immediate effect. 1st May 2005 1st May 2005 With immediate effect. 1st June 2005 Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 18 the homes respective policies for the protection of service users. (Requirement originated from inspection 14/10/04.) The person registered must ensure that two written references are obtained prior to the employment of any new staff and all gaps in employment history are explored. The person registered must ensure that all staff responsible for undertaking catering duties are appropriately trained in food hygiene. (Requirement originated from inspection 14/10/04). The registered person must introduce formal systems for the purpose of quality assurance and quality monitoring in the home. (Requirement originated from inspection 14/10.04). The person registered must ensure all staff receive supervision at least six times a year and that written records are kept of all supervision that takes place. (Requirement originated from inspection 14/10/04). The person registered must ensure that a photograph of each service user is kept in the home. The person registered must ensure all staff receive fire safety training updates on a quarterly basis. (Requirement originated from inspecton 14/10/04). 10. 29 19 Schedule 2 With immediate effect. 11. 30, 38 18(1) 1st June 2005 12. 33 24(1) 1st June 2005 13. 36 18(1), (2) With immediate effect 14. 37 17(1)(a) Schedule 3 23(4) 1st April 2005 With immediate effect. 15. 38 Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 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. 2. Refer to Standard 7 30 Good Practice Recommendations Explore opportunities to further develop sevice users involvement in care planning. Document a training plan for the home which identifies the training needs of each member of staff and the training to be undertaken to meet those needs. Westwood E52 S18697 Westwood V224927 170505.doc Version 1.30 Page 20 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 E52 S18697 Westwood V224927 170505.doc Version 1.30 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. 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