Inspection on 14/04/08 for Westwood House

This inspection was carried out on 14th April 2008.

CSCI found this care home to be providing an Good service.

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 House 29/05/07

Westwood House 30/11/06

Westwood House 22/11/05

Westwood House 05/05/05

Westwood House 07/09/04

Westwood House 06/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Westwood House 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW Lead Inspector Lesley Allison-White Unannounced Inspection 14th April 2008 10:30 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 House DS0000031586.V362419.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 House DS0000031586.V362419.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westwood House Address 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW 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) 01530 415959 01530 415990 db@westwoodcare.co.uk Systems Associates Ltd Mrs Rebecca Mary Taylor 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 Physical disability over 65 years of age (16) Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person to be admitted to Westwood House in categories DE(E), PD(E) or OP when 16 persons in total of these categories/combined categories are already accommodated in this home. 29th May 2007 Date of last inspection Brief Description of the Service: Westwood House is a care home registered to provide personal care and accommodation for up to sixteen older people that may also have a physical disability and / or dementia. The home is owned by Systems Associates Limited who have a number of care homes in the Midlands region. The home is located close to the town centre of Ashby De La Zouch and its shops, pubs, the post office and other amenities. It is easily accessible by private or public transport. The home is a converted house with a purpose built extension. This is a three-storey building and the people living there have access to all floors with the use of the passenger lift or stairs. The building has level entry access which is suitable for wheelchair users. There are eight single bedrooms without en suite facilities and four double bedrooms, one with en suite and three without en suite facilities. There are gardens to the front and rear of the building, which are accessible to all the people living in the home. The weekly fees for living at the home are based on levels of need. The minimum to maximum fee is £335 to £430 per week in 2008 - this information was provided by the Registered Manager on the day of the inspection. The home provides information to the people who live there and prospective people in the form of a Statement of Purpose that describes the services it offers, and a copy of the last Commission for Social Care Inspection (CSCI) report can be found in the hallway. Both can be provided to enquirers to give them a view as to the quality of life for the people who live there. A current copy of the Employers Liability insurance is also displayed in the hallway. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is on outcomes for residents and their views of the service provided. The home provides care for up to fourteen people. On the day of inspection there were fourteen people living at the home. The inspection took over six hours to complete. Preparation included examining inspection records and looking at the service history. This aided the inspection process by providing background information. Discussion was held with five people who lived there. Two people had memory problems and limited communication skills and indicated how they felt when asked questions. The primary method of inspection used was “case tracking”. This involved speaking with the people who use the service provided, looking at two peoples care plans and making observations. (Care plans are records about the care or support provided for an individual). All the required key standards were inspected during this visit. Previous concerns were dealt and new requirements were made at this inspection. The Registered Manager and the Deputy Manager assisted during the inspection. What the service does well: Peoples needs are assessed prior to living at the home, with the completion of a pre-admission assessment by an experienced member of staff and the process is continued during the trail period. Observed care practices seemed polite and unrushed encouraging the individual receiving help to assist where possible. People who spoke with the inspector felt they were treated with respect and dignity by all the staff that worked at the home. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 6 Relatives’ comments included ‘When my relative is ill they get sent to hospital. When they are unwell the staff will let me know. My relative has not had any falls since being here.’ ‘My relative has a shared room and screens are provided for privacy. I have noticed that when my relative spills food on their clothes or becomes soiled the staff are very good and will change my relative.’ ‘I have seen the optician here, visiting people.’ What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Westwood House DS0000031586.V362419.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 House DS0000031586.V362419.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples needs are assessed prior to living at the home, with the completion of a pre-admission assessment by an experienced member of staff and the process is continued during the trial period. EVIDENCE: Two people were case tracked. Three other people who lived at the home also spoke with the inspector and two relatives. People who lived at Westwood House and relatives said a Service Users Guide and Statement Of Purpose (This is information about the services the home offers) and contracts from the Company are provided. The Registered Manager or the deputy manager visited new people either at hospital or at home, to assess their needs. Copies of the placing authority’s community care assessment are kept in the individual’s records. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 9 A trial period is offered to new people, to give them a good idea of what services the home offers. There was evidence of assessments undertaken by the Registered Manager in the two case tracked peoples records. Intermediate care (Standard 6 is not offered at this home). Westwood House DS0000031586.V362419.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 good. This judgement has been made using available evidence including a visit to this service. Staff understands the key principles of giving personal support and are responsive to the varied and individual requirements of the people living at Westwood House. EVIDENCE: The inspector spoke with two people who lived at the home in detail. They explained that staff was always friendly and happy to help anyone who needed their help. Explaining their own personal experiences they said that they saw a General Practitioner (GP) when ill or if a nurse was needed to take bloods or to provide other forms of care this was also done. They were escorted to hospital appointments either by their relatives or by staff and more than one person said that the dental services called at the home. Observed care practices seemed polite and unrushed encouraging the individual receiving help to assist where possible. People who spoke with the inspector felt they were treated with respect and dignity by all the staff that worked at the home. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 11 Relatives’ comments included ‘When my relative is ill they get sent to hospital. When they are unwell the staff will let me know. My relative has not had any falls since being here.’ ‘My relative has a shared room and screens are provided for privacy. I have noticed that when my relative spills food on their clothes or becomes soiled the staff are very good and will change my relative.’ ‘I have seen the optician here, visiting people.’ On a practical level health care needs are being met, however evaluation within the care plans seen, should accurately reflect the changes that have taken place. For example an evaluation on someone’s medicines recorded on 12/03/08 was written ‘Care plan remains the same.’ However, on the 10/03/08 the GP visited and prescribed a medicine. The care plan and medicine kardex have this information recorded accurately and should have added this as a change in the evaluation section of the care plan. The Registered Manager explained that she would review the care plans again. In another persons records an old assessment chart is still in place. The chart mentions old moving and handling techniques such as Australian slide, through arm slide, combined slide as well as up the bed, using hoist. The person walks with a stick and needs one carer to assist her. However, a recommendation will be made to up date the forms used to record moving and handling information so that staff are not tempted to use moving and handling techniques now not practiced. A record of people who need night checks is kept in individual care plans. The staff record what the person is doing at the time of the check. Medications were checked and satisfactory. A Controlled Drug (CD) was also checked and satisfactory. This is a drug that has special procedures in place to ensure that it is not misused or mishandled. The medicine trolley is locked and kept fastened to a wall in the kitchen. This is not ideal. At time of the inspection the Registered Manager said that this was due to a shortage of alternative storage space. Westwood House DS0000031586.V362419.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 good. This judgement has been made using available evidence including a visit to this service. People living at Westwood House find the lifestyle in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests. People are able to maintain contact with family, friends and the local community. People are able to exercise choice over their lives. People receive appetising and nutritious meals in a pleasant environment. EVIDENCE: There were visitors present at the time of inspection that the inspector was able to speak with. People living at Westwood house felt that their relatives and visitors were made welcome by the staff that worked there. People who spoke to the inspector said that they regularly went out to coffee mornings held at the local church. Extra staff and relatives would also come in to help take them to the local church when needed. When the weather was good the Registered Manager at Westwood House arranged transport to take them out to local places of interest such as garden centres. People living at the Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 13 home and some of the relatives also said that people came to Westwood House to provide entertainment at regular intervals. People who spoke with the inspector said that they made their own choices as to when they got up in the mornings and went to bed at night or returned to their room to watch their television in their room. People who smoked cigarettes said that they went into the patio area of the garden when they need to have a cigarette. A meal at lunchtime was seen. It was a sociable occasion eaten in the dining room. On the day of inspection the deputy prepared the meal as the cook was on special leave. (Beef stew and dumplings, sweet was fruit salad as trifle had been served the evening before and a large tin of fruit salad had been opened and needed to be finished). The sweet had been changed but the menu board still had the original sweet menu on it. Staff should ensure that the menu reflects the food being served on that day as meals play an important part in life at the home. The menu board should be easily seen and in a more prominent place so that all the people living at the home can see it. Westwood House DS0000031586.V362419.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. People feel able to complain and are confident that they will be listened to and their complaint acted upon. People living at the home and their relatives feel they are satisfied with the service provision and feel safe and supported. EVIDENCE: The Commission for Social Care Inspection (CSCI) has not received any complaints about Westwood House since the last inspection. People who spoke with the inspector said that they felt that the staff was approachable and that they would go to either the Registered Manager or the deputy if they had any concerns or complaints. At the time of inspection the Registered Manager was unable to open the information on staff records to verify training records including training on abuse. However this information has been sent to the CSCI Cambridge office as discussed. Twelve staff currently all have Protection Of Vulnerable Adult (POVA) training and certificates. The Registered Manager explained that new staff would be put on the training once available again. They also receive an induction that includes safeguarding. Westwood House DS0000031586.V362419.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: People living at the home said that they were content with their bedrooms and happy they could bring in their own furniture. Screens are provided in the shared bedrooms for use. This gives people privacy and dignity if they wish to use them. Some bedroom doors have a photograph of the person who occupies the room to enable the person to recognise their room more easily and to help any new staff members to identify the person in the room. Toilet doors have labels on them to help someone with dementia identify where the nearest toilet to them is within the home. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 16 The stair carpet that was threadbare has been replaced. A new modern television (TV) has been bought and is in one of the lounges. The dining room carpet has been replaced and the general décor of the home has been refreshed. Further carpet replacements are due to take place in the front hallway and front stairs the Registered Manager explained. Westwood House DS0000031586.V362419.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. The skill mix of the staff meets residents’ needs. Competent staff supports the people living at Westwood House. People are protected by the recruitment policy and procedures at the home. Staff are trained and competent to do their job. EVIDENCE: The rota and the Registered Manager confirmed that there was a minimum of three care staff on duty during the morning and two on duty for the afternoon/evening period (unless the home has the full occupancy of sixteen residents when there are supposed to be three care staff on duty, however due to recent problems with staff illness or unexpected special leaves the rota has sometimes received minimum staffing levels of two people on each shift. Agency staff has also been employed to help provide care and on the day of inspection two new staff members who were not on the rota were receiving fire training as they waited for their references and Criminal Records Bureau checks (CRB’s) to arrive. These checks are done to protect vulnerable adults from potentially dangerous people. In addition there are catering and domestic staff. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 18 Information with regard to staff training was not seen at this inspection. The Registered Manager sent through this information later. The recruitment policy and staff records that were seen support the protection of the people who live at Westwood House. Staff receive training so that they are competent to do their jobs and receive induction. In the last report it was recommended that domestic and catering cover is extended to seven days a week. This has been done as far as possible. People living at the home said they were very happy with the staff team and said they are very helpful at all times. Westwood House DS0000031586.V362419.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is managed by a person who is fit to be in charge. The home is run in the best interests of the people who live there. Individuals’ financial interests are safe guarded. The health, safety and welfare of people who live at the home and staff are promoted and protected. EVIDENCE: The Registered Manager has been away from the home for a while due to unforeseen personal reasons however, the deputy manager has managed the home and there was evidence of Regulation 26 visits from the Provider. These are visits that the Provider must make to ensure that there are no problems left unresolved in the management of the home. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 20 The Provider sent out quality assurance monitoring forms to people living at the home in November 2007 although the inspector did not see these at inspection. Copies of two residents finances have been sent to the Commission for Social Care Inspection (CSCI) Cambridge office as proof of good financial management practices operated at the home. Measures for health and safety are monitored and the Registered Manager has forwarded copies of gas, electrical and fire safety information to verify that the home complies with current health and safety regulations. An improvement plan was sent to CSCI following the last inspection with regard to the water valves and the control of the temperature of water from the taps and the radiators seen around the home. The Registered Manager has verified that the home is managed safely. A requirement will be made, as the current recordings of temperature for the fridges are insufficient and would not detect when the fridge is not operating at the correct temperature. Recordings state ‘over 3 degree C’ (seen at 10o C in fridges 1 and 2). The deputy manager was made aware of this at the time and has promised to correct this immediately. Registered Manager also made aware at the end of the inspection. On inspection it was noticed that staff knocked at the back door to the kitchen and expected to be let into the home using this route. The deputy manager sent the staff to the correct door. However, it appears to have become a custom for some staff to do this. The Registered Manager said that she would address this issue. It was also noticed that some staff had mobile telephones with them and answered them on duty. The Registered Manager said that she would talk to staff about this also. Westwood House DS0000031586.V362419.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X X 3 Westwood House DS0000031586.V362419.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. 1. Standard OP38 Regulation 13 4 (c) Requirement Timescale for action 14/05/08 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 OP15 Good Practice Recommendations When the menu changes staff should ensure that the menu reflects the food being served on that day as meals play an important part in life at the home. The menu board should be easily seen and in a more prominent place so that all the people living at the home can see it. Westwood House DS0000031586.V362419.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 House DS0000031586.V362419.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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