CARE HOMES FOR OLDER PEOPLE
Westwood House 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW Lead Inspector
Mrs Bhavna Keane-Rao Unannounced Inspection 22nd November 2005 09:45 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.V267555.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 House DS0000031586.V267555.R01.S.doc Version 5.0 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 System Associates Ltd Ms Karen Lorraine Simpson 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.V267555.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 05/05/05 Brief Description of the Service: Westwood House is a care home providing personal care and accommodation for sixteen older people which includes older people who have a physical disability and dementia. The home is owned by Systems Associates Limited operators of a number of care homes in the Midlands region. The home is located close to the town centre of Ashby De La Zouch, close to 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 threestorey building and service users 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 is an adequate number of washing, bathing and toilet facilities for service users’ care and comfort which includes two lounge areas and a dining area. There are eight single bedrooms without en suite facilities and four double bedrooms one with en suite and three without en suite facilities. There is a garden to the front and rear of the building which is well maintained and which is accessible to all service users residing in the home. Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place during Tuesday morning. It took three and halfhours to complete. This home provides care for up to sixteen older people who may have a physical disability or dementia. Discussion was held with five residents. However other residents were observed in their daily routine. Three resident were spoken with in great detail. A resident’s relative was also spoken with in detail. One resident asked not to be disturbed. The primary method of inspection was speaking to the residents who use the service provided. All the required key standards were inspected during the last visit on 5th May 2005. Therefore only specific standards were inspected this time. All areas of concerns raised at the last inspection have been either been met or are in hand. A tour of the premises was undertaken and opportunity was taken to view resident’s daily records, MAR sheets, menus of meals and Staff Meeting. The assistant manager was on duty during the whole of the inspection. The manager was on premises but was assisting Extend, movement to music instructor. However the manager did participated towards the end of the inspection. The assistant manager spent time discussing many issues that arise in the running of a residential home and facilitated this inspection. What the service does well:
The registered manager and the staff at the home are very willing to learn and improve the service provided for the residents. One person stated, “ We are made very comfortable by the staff”. One person stated that they had a lot of activities organised for them, in particular the outside entertainers are appreciated. One person said “Yesterday a woman came to entertain us, she had a voice like an angle”. Another person stated that “I love playing bingo and the exercise classes which we are doing now.” The activities board lists all the activities that are arranged by the home. Some of these activities are facilitated by staff and some by outside entertainers Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 Page 6 A resident’s relative stated that this was a “lovely home”. 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. Westwood House DS0000031586.V267555.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 House DS0000031586.V267555.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): 4 The admission process is well managed and residents entering the home and know that their care needs will be met. EVIDENCE: All the required standards were inspected at the last inspection. The admission procedures are in place and assessments of individuals are carried out by health and/or social care professionals, as part of the referral process. There have been no new referrals to the home since the last inspection. Westwood House DS0000031586.V267555.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): 9 The system for administration of medication is safe. EVIDENCE: Medication is stored in a locked room and administered by staff that are trained. Administration of medication and recording was seen and is considered to be safe. There is a system in place where all areas of concerns are highlighted and dealt with promptly. Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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): 15 Residents’ dietary needs are met. EVIDENCE: Three of the residents spoken with stated that they liked the meals provided. One resident stated that he liked fish every Friday. There is always one main meal and an alternative if so requested. Number of residents stated that they loved the ‘special steak pie, which the cook makes’. This was on the menu of the day of the inspection. One resident, who was spoken with, stated that they can make their own drinks in the kitchen if they are able to, although no one wishes to do so. A relative who was spoken with stated that he is always offered a drink and encouraged to make one if would rather. He also stated that he was able to help out in the home and made to feel at home this was ‘very nice’. Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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): 18 Residents are safe and protected from abuse. EVIDENCE: All the required standards were inspected at the last inspection. Residents and their relative’s comment showed that people feel comfortable discussing concerns with the home’s manager and assistant manager. The complaints procedure is available for residents and visitors. Residents spoken with felt they were safe and protected. The adult protection procedure has been given to all the staff. Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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): 24 A comfortable, well-maintained, pleasant, clean and safe standard of accommodation is provided for the residents. EVIDENCE: All the required standards were inspected at the last inspection. The home is well maintained and suited to residents needs. There is ample natural light throughout the home. It is decorated and furnished to meet the needs of the residents. The décor creates a comfortable homely atmosphere. There are a number of lounge areas and a dining area leading to the back and the side of the home and garden. Entry to the home and to the garden is wheelchair friendly. The residents who were spoken with expressed their satisfaction with the physical state of the home. One bathroom is out of use as it is being decorated.
Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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): None EVIDENCE: All the required standards were inspected at the last inspection. On the day of the unannounced inspection there were two members of care staff on duty to provide care for the residents. In addition to this there is the cook, a domestic person and the assistant manager. The registered manager was also on premises to assist the Extend instructor with the movement to music session. Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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): None EVIDENCE: All the required standards were inspected at the last inspection. Residents who were spoken with were positive about the staff employed at the home. One particular residents relative stated that he could not thank the staff enough. The observed interaction between the staff and residents was relaxed and friendly Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 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 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Westwood House DS0000031586.V267555.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 House DS0000031586.V267555.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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