CARE HOMES FOR OLDER PEOPLE
Westwood Care Home 21 Doncaster Road Selby North Yorkshire YO8 9BT Lead Inspector
Jean Dobbin Unannounced Inspection 21st March 2006 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.V286398.R01.S.doc Version 5.1 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.V286398.R01.S.doc Version 5.1 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.V286398.R01.S.doc Version 5.1 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 13th December 2005 Date of last inspection Brief Description of the Service: Westwood Care Home provides 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 is an old detached two-storey building with ten single and three double bedrooms, which are on both levels. 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.V286398.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This summary relates to an unannounced inspection on Tuesday 21st March 2006, lasting over 5 hours including preparation work. The registered manager was present throughout the visit. The inspection included a tour of the residents’ areas, both communal and private; as well as looking at some policy documents, a recruitment file and records of how the resident’s care is planned and assessed. The record of accidents within the home was discussed. A grumble about how a residents’ clean clothing is managed has been resolved in accordance with the home’s complaint’s policy. Staff were observed interacting with residents and there was the opportunity to talk with five residents, two members of staff and a visitor. What the service does well: What has improved since the last inspection?
There is ongoing refurbishment at Westwood. Currently the layout to the entrance area is being altered prior to complete redecoration. Two bedrooms have had damp problems addressed, with some re-plastering work, and have been re decorated in accordance with the residents’ preferences. There has been a concerted and continued effort to address intermittent malodours that occur from time to time in private areas within the home. (These were requirements from the previous inspection) There are more improvements planned and many residents know what’s going on. Staff continue to work
Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 Page 6 towards NVQ Level 2 in Care, with more than half the employees either completed or working towards the qualification. 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.V286398.R01.S.doc Version 5.1 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.V286398.R01.S.doc Version 5.1 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): None EVIDENCE: Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 The residents’ personal, social and healthcare needs are well addressed. EVIDENCE: A number of care plans were sampled, which demonstrated that the documentation is comprehensive, with a common format, so they are easy to read. Indeed the documentation is to a very good standard. There are risk assessments in place, for both the environment and in how individual needs can be met. Both these and the care plans are reviewed monthly, to ensure that they are still valid and appropriate. The management must ensure though, that all records are signed for. Staff should consider discussing and reviewing the care plan with the resident, when appropriate, so that the resident can say what is important to them, and be involved in goal setting. There also need to be risk assessments in place for those residents unable to use the call bell at night. This assessment ensures residents can continue to be supported safely and consistently at all times. Residents have access to a range of health care professionals. One resident stated that she always sees her doctor and chiropodist in her bedroom and can request a visit if she wishes. There is documentation to evidence these visits. One resident has very poor sight and she has received support and advocacy from a local organisation helping people with sight difficulties, which has enabled her to remain as independent as possible.
Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 the following standard(s): 14 Residents are supported in making decisions about how they choose to live. EVIDENCE: Residents are encouraged and enabled to make choices about how they live their lives. One resident said that she didn’t like joining in activities, but was always asked in case she changed her mind. Residents were asked where they wished to sit for lunch. One resident, who was very anxious, didn’t want to sit down or have anything to eat at lunchtime. The staff said that they would prepare something for her when she was more relaxed and a member of staff stayed with her. A flexible plan of care means that residents can still be supported even when they do not follow the home’s routine Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 the following standard(s): None EVIDENCE: Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 the following standard(s): 19,26 There are systems in place to ensure residents’ lives are not being unduly affected by the refurbishment within the home, however some areas need to be prioritised for redecoration. EVIDENCE: These standards were not fully inspected, but previous requirements were checked at this time. One bedroom was reported as having an unpleasant odour, which the manager has addressed with varying success. On the day of the visit there was an odour apparent, which had gone three hours later. The manager and her staff are alert to the problem and work hard to eliminate malodours to ensure that all the residents live in a pleasant environment. The room identified as having a damp problem has been repaired and redecorated. One bedroom has a hearth and uneven flooring evident under the carpet. The resident using this room has a walking aid, and whilst the room has been identified for redecoration, this should be prioritised to ensure the risk to the resident, associated with the flooring, is removed as soon as possible. Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 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): 29 A robust recruitment policy ensures that residents are protected by good practice EVIDENCE: The recruitment file for the latest employee was examined. This showed that all pre-employment statutory checks had been carried out. Residents can feel confident that they are not put at risk by poor practice. Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 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): 33 Some systems are in place to audit how the home is run; however information needs to be sought from the residents. EVIDENCE: The management team are aware of the importance of seeking feedback from interested parties to strive for continued improvement. There has been no survey completed to outline the residents’ views, but the manager has now identified an appropriate tool she can use to gain that information. The manager has conceded that regular residents’ meetings have lapsed recently and this is an area she needs to address. Residents need to have the formal opportunity to voice their views about how the home is run, however residents’ opinions are sought and they are kept up to date in an informal manner. These informal conversations though, are often unlikely to be recorded. .Relatives, care managers and visiting healthcare professionals have completed specific questionnaires and these results have been made available for viewing in the main entrance area. The feedback is very positive.
Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 13 (4)a Requirement The bedroom with the uneven floor requires work to make the floor level Timescale for action 01/05/06 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 written. There should be risk assessments in place for those residents unable to use their call bell at night. The previously regular residents’ meetings need to be restarted. The questionnaire, which has been identified, needs to be used to gain feedback about what residents feel about the home. 2 OP33 Westwood Care Home DS0000059032.V286398.R01.S.doc Version 5.1 Page 17 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
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