Inspection on 13/12/05 for Westwood Care Home

This inspection was carried out on 13th December 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westwood Care Home 21/11/06

Westwood Care Home 21/03/06

Westwood Care Home 18/10/04

Westwood Care Home 11/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Care Home 21 Doncaster Road Selby North Yorkshire YO8 9BT Lead Inspector Pauline O`Rourke Unannounced Inspection 13th December 2005 09:30 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 Care Home DS0000059032.V269256.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 Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westwood Care Home Address 21 Doncaster Road Selby North Yorkshire YO8 9BT 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) 01757 709901 01757 709901 Holistic Care Provision Limited Mrs Yvonne Ann Clark Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (16) of places Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users up to 16 DE(E) and up to 16 OP up to a maximum of 16 Service Users 18th October 2004 Date of last inspection Brief Description of the Service: Westwood Care Home is a care home providing personal care and accommodation for to up to sixteen older people who may have dementia. It is one of two homes in the area owned and run by Holistic Care Provision Ltd. The home is located on a busy road in the market town of Selby and is close to shops, a post office and other local amenities. The home consists of a detached two-storey building. It has ten single bedrooms and three double bedrooms. One single room and one double room have en-suite facilities. The home has a large garden that is well maintained and is easily accessible. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection including preparation time took place over 10 hours. A tour of the building was conducted. A number of the service users records, staff records and records about the management of the home were inspected. 8 of the service users, 3 visitors, a district nurse and 6 of the staff on duty were spoken with. What the service does well: What has improved since the last inspection? Since the last inspection there has been a continued push to ensure that staff have the skills required to enable the service users to remain as independent as possible. There is a monthly training plan, for staff as well as one-off courses covering a variety of topics associated with older people. Improvements in the environment have included; an extensive and complete refurbishment of the kitchen knocking down the cubicle toilets, creating a new laundry, creating a staff office on the ground floor, created a large assisted toilet, completely refurbished the assisted bathroom on the ground floor, replaced a flat leaking roof with a new pitched roof and demolished and rebuilt the garage to provide extra storage. All the works have been completed to a high standard. Westwood Care Home DS0000059032.V269256.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 Care Home DS0000059032.V269256.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 Care Home DS0000059032.V269256.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): 3 and 6. The service users can be assured that their care needs will be met. EVIDENCE: The service user files seen contained copies of an assessment by a care manager and the registered manager. This information is used to develop an initial care plan. The manager confirmed that she does try to visit all prospective service uses before their admission, but this is very much dependent on where they are coming from. Where a visit cannot be made then the first two week of any stay is seen as an assessment period. Service users spoken with confirmed they had seen someone from the home prior to their admission. The home does not provide intermediate care. Westwood Care Home DS0000059032.V269256.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, 8, 9 and 10 The health, social care and personal needs of the service users are met. EVIDENCE: The service user files seen contained a Care Plan. This document is developed from the assessment information and those seen were pertinent to the individual concerned. Service users spoken with were aware of their plans. Staff confirmed that they review the plans each month, although as a matter of good practice staff should sign and date any changes to the plan. The service users files contained information about their health needs, details of GP visits and district nurses are recorded. The service users spoken with said that they could see their GP on request and that any visits made either to the home or the surgery were in private. A visiting District Nurse said that the home worked with them and followed treatment plans. She felt the service users received a good quality service at Westwood. Staff were observed treating the service users with respect at all times. The service users said that staff always treat them with respect and try to preserve Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 10 their dignity at all times. The service users spoken with said that the staff were ‘first class’ and ‘always very friendly’. There is a medication policy in place and all staff that administer the medication have received appropriate training. The storage, dispensing and documentation of the medication was in line with the policy and procedure of the home. Medication was seen to be administered during the inspection and the member of staff followed the homes procedure at all times. Staff spoken with said that they had enjoyed the learning distance-training course in the Safe Handling of Medicines. Westwood Care Home DS0000059032.V269256.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 and 15. The service users are able to keep their own routine within the home and join in with social activities. The service users have a varied and balanced diet. EVIDENCE: Records inspected, comments by service users and observations made during the inspection all identified that routines within the home were relaxed and geared to meet the needs and wishes of the service users where at all possible. Activities are organised on a regular basis within the home. Activities tend to take place on a daily basis and this can be a sing-a-long, talking with the service users, reminiscing or interacting with the visitors. During the summer months trips are organised and the service users had particularly enjoyed a visit to Knowsley’s Safari Park. Visitors spoken with said that they are always made welcome and there are no restrictions as to when they visit. The service users confirmed this was the case. One visitor said that the managers were good at keeping them informed about events affecting their relative or generally what’s going on in the home. A visitors’ policy is in place and all visitors sign a visitor’s book on entering the home. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 12 The service users spoken with expressed satisfaction at the quality and quantity of the food provided. They confirmed that an alternative to the main choice is available at each meal. The meal observed was relaxed and the staff assisted service users appropriately where necessary. The menu was examined and appeared to provide a balanced and nutritious diet. The cook explained that local fresh produce is used and they are able to vary the menu to include seasonal foods. Westwood Care Home DS0000059032.V269256.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 and 18 Service users were confident that any complaints or concerns they had could be raised and acted upon. Service users are protected from possible abuse through staff training and thorough recruitment procedures. EVIDENCE: There is a detailed complaints policy in place. This policy is provided to all the service users and is displayed around the home. There have been no complaints made to the CSCI or the home in the last 12 months. Service users spoken with all said that if they had any problems there was someone within the home they would go to. There is an Adult Protection Policy in place. Staff spoken with had received training in Adult Protection issues and they had a good understanding of their responsibilities if they believed any inappropriate behaviour was taking place. Policies are also in place regarding the management of service users money. Staff are also subject to a criminal records bureau disclosure and a protection of vulnerable adults check to ensure that they are suitable to work in a care setting. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The environment service users live in is in need of repair and updating. EVIDENCE: The home is suitable for its stated purpose and meets the requirements of the local environmental health office and the fire and rescue service. Whilst maintenance is planned there were several areas identified to the registered manager during the inspection as requiring immediate attention. One area in particular concerned a service users bedroom that clearly had signs of damp on the external wall causing the brickwork to crumble and the paper to lift. The room also smelt foisty. Other rooms identified had paint peeling from the ceiling, and carpets clearly showing the imprint of the floorboards underneath. The floorboards were uneven and needed attention to prevent them from becoming a potential tripping hazard. The home is generally tired and would benefit from redecoration. The communal area and the majority of the bedrooms seen were clean, warm and free from odour. One bedroom was identified to the registered manager during the inspection as having a malodour. The service users said that the home was always kept clean and tidy. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 Staff receive regular training that enables them to provide appropriate support to the service users. Staff are thoroughly vetted prior to their deployment. EVIDENCE: The staffing levels provided are sufficient to meet the needs of the current service user group. At the time of the inspection there were 3 carers, 1 student carer, a domestic, a cook and the manager on duty. All staff were observed assisting and interacting with the service users. 4 staff files were seen and they all contained the documentation as required by the Care Homes Regulations 2001. All of the start dates corresponded with the Criminal Records Bureau disclosure date. The manager said that where necessary POVAFIRST checks are carried out prior to the commencement of their employment. A training plan is in place and in the month of November staff had access to bereavement training, food hygiene, health and safety, infection control, moving and handling, abuse and challenging behaviour, oral care and communicating with people with dementia. The registered manager is working towards 50 of the staff being qualified with a National Vocational Qualification level 2, at his time of 16 care assistants employed at the home 5 have either a level 2 or a level 3. 4 staff are in the process of completing their level 2 and a further 3 members of staff have just started their National Vocational Qualification level 2. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The service users live in a well managed home. Policies and procedures are in place to ensure the service users’ financial interests are safeguarded. The health and safety of the service users and staff is promoted. EVIDENCE: The registered manager has obtained the Registered Manager Award and has done 3 units of a National Vocational Qualification level 4 in Care. She is an experienced manager and staff spoken with said that she was always approachable and operated an open door policy. Service users and staff said that she spends a high proportion of her time with them. A policy is in place that informs the staff on what their responsibilities are in relation to the service users financial situation. Several service users have their money held by the office. 4 of the records were examined and found to be accurate and up to date. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 17 The staff spoken with during the inspection said that they had received training in, back care, first aid, food hygiene, COSHH, and fire training. The equipment used in the home is serviced at the prescribed intervals. Health and safety notices were displayed around the building. Accidents are properly recorded and where necessary reported to the Commission for Social Care Inspection. Information from the accident records is used in the care planning process. All staff can access Induction and Foundation training, this provides them with basic skills required to undertake the role of care assistant. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)b Requirement The room that was identified as being damp must be put right as soon as possible. The rooms identified to the registered manager as requiring attention to the floorboards must be put right as soon as possible A plan must be submitted to the Commission for Social Care Inspection to show a timescale for the décor to be updated. Staff must ensure that the one bedroom identified as having a malodour is kept odour free at all times. Timescale for action 10/01/06 23(2)d 2 OP26 16(2)k 10/01/06 Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 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 OP7 Good Practice Recommendations All care planning documentation should be signed and dated when first developed and then at each change. Westwood Care Home DS0000059032.V269256.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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