Inspection on 26/06/07 for Westwood Hall

This inspection was carried out on 26th June 2007.

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 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

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Hall Brimstage Road Brimstage Wirral CH63 6HF Lead Inspector Jeanette Fielding Key Unannounced Inspection 26th June 2007 10:20 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 Hall DS0000069024.V336782.R01.S.doc Version 5.2 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 Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood Hall Address Brimstage Road Brimstage Wirral CH63 6HF 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) 0151 342 2150 0151 342 4076 Activecare Limited Kathleen May Gratwick Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 52 service users to include:Up to 52 service users in the category of OP (Old age, not falling within any other category). This is the first inspection under the ownership of Activecare Ltd. Date of last inspection Brief Description of the Service: Westwood Hall is a large care home providing nursing care to older people. It is situated in a pleasant rural setting near to Heswall on the Wirral. The care home lies in its own extensive grounds, which are attractive and well tended. There is ample car parking to the front of the home. The internal decorations of the home are good, with communal lounges and conservatory for service users to use as they wish. The majority of service users are accommodated in single bedrooms, some having en suite facilities. Local amenities such as shops, cafes, churches and a library can be found in Heswall. The home has recently changed owners and is now owned by Activecare Ltd. There has been no change to the Registered Manager of the home. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection, the owner of the home has changed. There has been no change in the day-to-day management of the home or of the care provided. This inspection was conducted in one day over a period of six hours. During the inspection, the care files of service users were inspected. These were found to be of a high standard and included full information about service users needs together with details of the actual care given. Staff files were inspected and were found to contain all necessary information to ensure that service users are protected. A tour of the premises showed that all areas are furnished and decorated to a high standard, were clean and well maintained. Discussion took place with the manager and staff and all were able to demonstrate that they were aware of all service users individual needs. Service users were spoken to and were very complimentary about the staff, the home and the care afforded to them. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to develop to provide the current high standard of care and facilities for the service users. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 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 Hall DS0000069024.V336782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed pre-assessments are undertaken on all prospective service users to enable a plan of care to be prepared and enable the staff to provide the appropriate level of care to each service user. EVIDENCE: The new owners of the home have produced a statement of purpose and a service user guide as part of the registration process. These documents are available from the home on request. Pre-admission assessments are undertaken on all prospective service users. The manager or one of the qualified nurses visits the service user in their own home or in hospital as appropriate to gather the information and complete the comprehensive form. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 9 Information is gathered from the service user, their family and any healthcare professionals involved in their care. The details are recorded on a designated form and the information is used to prepare a plan of care. Information is gathered regarding the service users’ medical, health, personal and social care needs together with any individual preferences. Specialist equipment necessary to meet the service users needs is identified and gives the home the opportunity to provide this prior to the service users admission. The care files of service users recently admitted to the home were inspected and all were found to contain extremely detailed and informative assessments. Prospective service users are encouraged to visit the home or stay overnight before moving in on a long term basis to give them the opportunity to view the room, meet other service users and to make an informed decision regarding their care provider. The home does not offer intermediate care. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are prepared to enable the staff to provide the appropriate level of care to each individual service user. EVIDENCE: Individual care plans are prepared for all service users. These are reviewed and amended on a monthly basis, or on the changing needs of the service user, by the senior nurses. Extremely detailed plans are prepared and comprehensive risk assessments are undertaken. These include falls, the use of bed rails, the use of wheelchairs, moving and handling, health and safety, nutrition and any other need appropriate to the service users health needs. Care plans are prepared for all these and provide the staff with detailed information on the care to be given. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 11 The owners of the home have introduced a new format for care plans. Some of the plans have a different layout and so the manager and nurses have included the original plans in the care files to ensure that full information regarding the service user is included. The home also has a ‘getting to know you’ form which is completed by the service user, their relatives and the staff to provide additional information regarding the service users past life, their skills, hobbies and details of significant family and friends. Staff spoken to during the inspection said that this information had proved to be extremely helpful in understanding the service user and is an aid to the provision of social activities and conversation. The nurses complete daily reports, and the care staff complete a record of the actual care given to service users on a daily basis. The care records are therefore comprehensive and informative and provide evidence that the service users’ health care needs are fully met. Staff actively promote the service users’ right of access to the health and remedial services that they need, both within the home and in the community. Regular appointments are seen as important and there are systems in place to make sure appointments are not missed. Records show that the home arranges for health professionals to visit frail service users in the home and provides facilities to carry out treatment. Staff keep a regular check on health aids, making sure they are working effectively and that each service user has the necessary aids to improve their quality of life. Records held in the home provide evidence of the input by other healthcare professionals and advice is sought from District Nurses and the Tissue Viability Specialist Nurse as necessary. Service users have choice over their personal care and are encouraged to be independent and responsible for their own personal hygiene where possible. The home has a robust medications policy and inspection of the medications records provide evidence that the staff follow the procedure. All records relating to medications were found to be well maintained and up to date. The medications room and trolleys were seen to be clean and organised. Appropriate arrangements are in place for the disposal of unwanted medications through a contract with a disposal company. Service users were observed to be treated with sensitivity and respect. Service users spoken to during the inspection spoke extremely highly of the staff and of the care that was given to them. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A high number of activities are provided for service users to provide them with a range of social opportunities and stimulation. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident, and family members, are asked to complete a “Life Story” questionnaire, which is a “Work life History” of the resident, and includes a chronology of their schooling, work, hobbies, food likes and dislikes etc. The home employs an activities co-ordinator who, with the assistance of an enthusiastic and extremely committed group of relatives, provides a full programme of social activities to provide stimulation and entertainment for the service users. Records are held of all activities that service users participate in. A summer fair has been planned for the week following the inspection. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 13 A relative’s forum meets regularly and minutes are taken. These are displayed on the notice board within the home. Funds are raised by the group who have recently purchased a new DVD player and DVD’s. Sunhats have been purchased for use when the sun shines to protect the service users. A programme of forthcoming activities is displayed and a regular Newsletter is produced. Recently, a local Brownie group visited the home and sang for the service users. A minibus is available each fortnight and recent trips include Goredale Nurseries and Parkgate. Visitors are welcome at any reasonable time of the day and service users may meet with their visitors in their own bedroom or in one of the communal areas. Ministers of Christian religions provide weekly services in the home and a list of ministers of other religions who can be contacted is held. Service users can take their meals in the dining room, the lounge or in their own bedroom as they prefer. Tables in the dining room are attractively laid and trays, again, attractively laid, are provided for those who take their meals in other areas of the home. The menus inspected show that a varied and balanced diet is offered and that a choice of meals is available. The menu is changed on a regular basis according to season and on the request of service users. The kitchen is clean and organised and is well stocked. All foods were seen to be stored appropriately and all necessary equipment is provided. Special diets can be provided on the advice of the GP or dietician or on the request of the service users. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good knowledge and understanding of Adult Protection issues which protects service users from abuse. EVIDENCE: The home has a robust complaints procedure which is detailed in the service users guide, the staff handbook and is displayed on the notice board in the home. No complaints have been received by the home or by CSCI since the last inspection. The home has up to date information on the Protection of Vulnerable Adults, this information is communicated to new employees on their induction course. There was evidence that all staff in the home had undertaken training on POVA protocols, and the Whistle Blowing Policy. Discussion with staff provided evidence that they were fully aware of different types of abuse and of the action to be taken in the event of it being suspected. Appropriate checks are made on staff prior to them commencing work at the home to ensure the protection of service users. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recent investment has improved the appearance of the home to provide a comfortable and safe environment for the service users. EVIDENCE: Westwood Hall provides accommodation in 48 single bedrooms and two double bedrooms which are available on request. Most of the bedrooms are provided with en-suite facilities. A programme of improvements and redecoration has been prepared. A new nurse call system has been installed and has proved most effective. A number of bedrooms have recently been redecorated and fitted with new carpets and curtains. Plans are in place for the next year when the bathrooms and the Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 16 front lounge and conservatory will be redecorated, and the carpet in the corridors replaced. Communal areas are bright and homely and are furnished and decorated to a high standard. Service users are encouraged to decorate their bedrooms with photos, pictures and items of memorabilia. All bedrooms inspected were found to be decorated and furnished to a high standard. All areas of the home were found to be clean and fresh and the home is well maintained. Sufficient toilets and bathrooms are provided throughout the home and bathing aids are provided to assist service users and to promote their independence. The extensive gardens have a fish pond, plants, flowers and hanging baskets. Seating is provided in the gardens which service users may use as they wish. The gardens are maintained to a very high standard. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training continues to develop knowledge and understanding and ensure that service users needs are met more effectively. EVIDENCE: The home employs qualified nurses who are supported by care staff at all times. The hours worked by the manager are supernumerary. The home has a robust recruitment procedure and the staff files inspected provided evidence that all checks are made on staff prior to them commencing work at the home. Prospective staff are required to complete an application form prior to being called for interview. Two references are required and checks are made through the Criminal Records Bureau. Gaps in employment history are investigated and a record of the interview is held on the staff files. Staff records were found to be in order and the home is currently recruiting for the positions of a kitchen assistant and a night care assistant. All new staff are required to follow a set induction training programme, evidence of which is Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 18 held on the staff files. New staff shadow existing staff and are supernumerary until they are assessed as competent. The home is committed to ensuring that staff training continues. Records are held of all training undertaken by staff and a list of forthcoming training opportunities was displayed. Recent training undertaken by nursing and care staff includes palliative care, tissue viability, fire prevention, POVA, manual handling and infection control. One member of staff has completed mentorship training. Kitchen and laundry staff have recently undertaken training on COSHH. Records are held on staff files of training undertaken. Service users spoken to at the time of the inspection spoke extremely highly of the day, night and ancillary staff. Their caring attitude and attentiveness were praised together with the knowledge and efficiency. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a robust and effective management structure in place to ensure the protection of all staff and service users. EVIDENCE: The registered manager is a qualified nurse who has considerable experience in the management of care homes for elderly people. She has now achieved an NVQ in management at level 4. The manager was able to demonstrate that the home was run in an open and transparent manner and in accordance with equal opportunities. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 20 Staff meetings are held on a regular basis and the minutes of these meetings were available for inspection. Staff spoken to during the inspection said that the meetings had been extremely beneficial, particularly during the recent change of ownership of the home. The meetings gave the opportunity to obtain all relevant information, raise and discuss issues of concern and remove any insecurities. Supervision is given to all staff and annual appraisals are undertaken. Records of these are held securely in the home by the manager. The home also has a relatives and residents forum. Meetings are held regularly and the forum is well supported. Service users or their representatives attend to service users financial matters and the home does not hold any bank accounts for individual service users. Policies and procedures have been reviewed and updated as necessary. Regular quality audits are undertaken through questionnaires which are issued to all service users and their relatives to obtain their views of the home and the service provided. The outcomes of the audits have enabled the manager to identify areas of the service provision which could be improved on, and has made changes accordingly. A representative of the owner visits the home each month and prepares a report for the owner and manager. Copies of these reports are held in the home. All safety checks have been made on the premises and equipment and the certification to provide evidence of these checks were well maintained and up to date. All health and safety issues were addressed with an excellent communication system in place to for staff to report any issues or repairs which require to be dealt with. Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 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 3 3 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTE3CTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 4 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 4 x 4 X 3 X 4 3 Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westwood Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hall DS0000069024.V336782.R01.S.doc Version 5.2 Page 24 - 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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