Inspection on 05/05/05 for Westwood House

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Westwood House 14/04/08

Westwood House 29/05/07

Westwood House 30/11/06

Westwood House 22/11/05

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 Bhavna Keane-Rao Unannounced Thursday, 5 May 2005 at 9:30am th 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 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 C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westwood House Address 35 Tamworth Road Ashby De La Zouch Leicestershire LE65 2PW 01530 415959 01530 415990 None System Associates Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Karen Simpson Care Home 16 Category(ies) of OP - Old age (16) registration, with number of places PD(E) - Physical disability - over 65 (16) DE(E) - Dementia - over 65 (16) Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 07/09/04 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 C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during Thursday morning and early afternoon. A number of residents were spoken with, but detailed discussions were only held with four of them. One resident asked not be disturbed. Two residents’ relatives were spoken with regards to the care provided in the home. A tour of the premises was undertaken and opportunity was taken to view residents daily records, menus of meals, fire records, a staff rota and staff records. The registered manager, spent time discussing many issues that arise in the running of a residential home and also facilitated this inspection. What the service does well: What has improved since the last inspection? There has been training provided since the last inspection. In particular there has been training on Moving and Handling and National Vocational Qualification 2 for all staff. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 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 standard(s) 2,3,4 and 5 Information about the home is provided from the earliest opportunity and at regular intervals. The admission process is well managed and reflected in the records. This enables residents to have a clear, informed choice regarding their stay in this home. EVIDENCE: Individual records are kept for each resident. Records viewed for three residents living at the home contained essential information on how the resident can be assisted to continue living independently. A new resident’s relative, who was spoken with during the inspection, said that she and her mother, received a warm welcome from staff and were given clear information about the home before, during, after the first visit and after their arrival. Residents and their relatives who were visiting felt they were kept informed of any events and changes within the home through information displayed on the notice board and from the staff. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 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 standard(s) 7,8,9 and 10 Residents are well looked after having their health and social care needs generally met. Management of medication in the home is not satisfactory and so must be reviewed. The guidance on administration of controlled drugs procedure is not followed. There is serious lack of understanding about safe use of wheelchairs. Residents’ records are generally accurate and clear. Residents’ privacy is upheld and they are treated with respect. EVIDENCE: Recording in the residents’ plans of care set out clear preferences and assistance required for residents to continue living as independent as possible, depending on care needs. Residents who were spoken with were not able to have detailed discussion due to their care needs. However relatives of two residents were spoken with in detail. A visiting district nurse was also spoken with, who was positive about the home and the way in which instruction were carried out. Four residents care plans were case tracked, it was noted for one person that their care needs had changed however the care plan was not up dated. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 10 All the residents are on electoral register and have now received their voting cards for the elections. During the inspection it was noted that a number of staff were using wheelchairs without the footrest. Thus residents’ feet were either hunched up or dragging. This practice is totally unacceptable and the manager and the responsible individual has been asked to address it immediately. Another issue was that the hairdresser was seen taking residents from the lounge to another area of the home to have their hair done in a shower chair. This did not have a footrest and the hairdresser is not trained to move residents nor is she trained to use the hoist. Medication is stored in a small locked medical room off the dining room and is administered by staff who are trained. Administration of medication and recording was seen and is considered generally to be to be safe. However there is one area of concern with regards to the recording of controlled drugs. In one case the name at the top of the sheet in the Controlled Drugs Register was different to the one printed at the side of the sheet. This could have led to a serious incident, however the manager stated that the correct medication was given to the right person in this case. This procedure must be reviewed immediately before there is a serious incident. Observations in the lounge and the dining areas showed that staff have a good awareness of how to speak with residents with curtsey and kindness. Two members of staff were observed speaking to the residents in the lounge. They were very polite and friendly. This created a relaxed and homely atmosphere. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Residents have a stimulating and varied life at the home with flexibility and are free to receive visitors. There is a range of activities made available for residents to join in with. There are good choices of meals that are nutritious and balanced. EVIDENCE: Staff undertake activities with residents both individually and in groups. Residents relatives spoken with gave examples of how the home satisfies their relatives’ choice of daily living at the home, the social and recreational interests. There are regular arms and legs exercise, chair aerobics, bingo and both internal and external entertainment. Residents were seen receiving visitors and comments received included “she is well cared for and is happier”. Residents were observed moving freely around the home, some with the assistance from the staff. There are no formal residents and relatives meeting held at the home. The manager has stated that she is thinking of holding theses in the near future. At present staff have regular chats with residents and their relatives. Menus are nutritionally balanced and appealing. The menu is displayed in the dining area giving a choice of two main meals. Residents and their relatives Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 12 spoken with said the meals were generous and good. Records showed the residents particular preferences and dietary needs. Relatives of residents are always welcomed to join their relatives and have meals at the home. This is considered to be a good working practice. A relative confirmed that everyday at 11am residents are offered sherry, tea, coffee or a soft drink. This was also observed to be the case. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Resident’s relatives are confident in discussing any issues of concerns with the staff or the manager before it leads to a complaint. Although there are policies and procedures in place for protecting adults, these must be reviewed as the staff are not aware of them and so can lead to residents being left vulnerable and at risk. EVIDENCE: Residents and visitors comments showed that people feel very comfortable discussing any concerns with the home’s manager. The complaints forms are available for residents and visitors. One complaint has been received since the last inspection. This was anonymous complaint with regards to staffing levels being too low. There has been an increase in the number of residents living at the home and the providers have therefore increased the number of staffing hours last week. Residents spoken with felt they were safe and protected. The adult protection procedure has been reiterated to all the staff. Two members of staff were spoken with, one member of staff showed a lack of awareness of the Vulnerable Adults Procedure and the other member of staff was able to clearly demonstrate the value of having a whistle blowing procedure. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 A comfortable, well-maintained and safe standard of accommodation is provided for the residents. The areas of residents’ dignity must be addressed with regards to offensive odour in bedrooms. The atmosphere in the home is warm and welcoming. EVIDENCE: As there are a number of residents who are confused at this home all communal areas are labelled and all the bedrooms have the name of the residents on the doors. This is considered to be very good working practice. A relative of a resident who was spoken with was very positive about the décor of the home and in particular about the ‘beautiful’ dining room. There are fresh flowers on all the dining tables and around the windows. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 15 The residents and the relatives who were spoken with were very pleased with their bedrooms and were observed using the communal areas freely. Areas in need of work, identified at this inspection are as follows: • • • • • • • • • • • • Bedrooms 4 and 7 had strong offensive odour. One unoccupied bedroom is used for storage. One bathroom is being used for storage. The wallpaper in one bathroom is peeling off. The bathtub in the upstairs bathroom needs to be cleaned. The sink in the upstairs bathroom has lime scale and so needs to be cleaned. There is extensive dust on the downstairs toilet wall. The curtains in bedroom 7 are fall off the rail. In bedroom 7 the base of the bed has worn away and needs to be replaced. The carpet in the hallway area is looking worn. There is damage to the left side of the wall next to the lift downstairs. At present there is only one hoist and is used downstairs usually. However the care needs of a particular resident has deteriorated and so the hoist is being dismantled to take it upstairs when needed. This is due to the size of the lift. This working practice is obviously unacceptable, however another hoist has been ordered It was noted that the hairdresser uses one of the residents’ bedroom. This has been agreed with the occupant and her family. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The staff at the home are competent and able to provide for the general care needs of residents at the home. There is ongoing training to ensure that all the staff are providing high quality care. Staff at the home do not know how to use a wheelchair safely. The staff members try hard to ensure that they meet the care needs of residents. EVIDENCE: On the day of the unannounced inspection there were two members of staff on duty to provide care for the residents. In addition to this there is the cook, the manager and an additional person who works at peak times. The home is registered to provide care for up to 16 residents. The following areas of concerns were identified: • A senior member of staff had not been trained with regards to Vulnerable Adults Procedure. She is left in charge of other care staff. • Staff were seen observing the hairdresser wheeling residents in a shower chair from the lounge to an area where she did their hair. • On a number of occasions staff were observed taking residents around in a wheelchair without footrest. On one occasion there was only one footrest was used. Two staff training files looked at during the inspection visit showed that training was made available to all staff on a regular basis, which includes moving and handling, first aid and food hygiene. All relevant paper work was also available. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35 and 38 Residents and their relatives are consulted about living in the home. The residents’ finances are safeguarded with a robust system. Residents and staff’s health, safety and welfare are being promoted and protected. The manager has an ‘open door policy’ which enable the staff and the residents to access to her at anytime. EVIDENCE: The staff and the residents who were spoken with felt that they could go to the manager at any time with any concern. The home has a maintenance programme for the home and the equipment. A random sample of records checked was up to date including fire drills. During the tour of the home, fire exits were clearly marked and were not obstructed. Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 3 x 3 x x 3 Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 19 No 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. 1. Standard 7 Regulation 15 Requirement It is required that care plans are reviewed and up dated as and when the care needs of residents changed. It is required that risk assessments are carried out on all identified areas of concern. It is required that staff are trained to use wheelchairs correctly. It is required that only staff employed by the registered providers or other trained health care professionals move residents using wheelchairs. It is required that shower chairs are not used instead of wheelchairs to move residents around the home It is required that correct procedure is used when dealing with controlled drugs as per the homes own Safe Handling of Medication procedures. It is required that all members of staff are given training on the procedures to be followed when allegation of abuse is made ie the Mistreatment of Vulnerable Adults procedure. It is required that communal Timescale for action Immediate 2. 3. 4. 8 8 8,22 13 13,18 12,13,18 Immediate Immediate Immediate 5. 8 12,13,18 Immediate 6. 9 13 Immediate 7. 18,30 18 01/06/05 8. 19 13,23 Immediate Page 20 Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 9. 10. 11. 12. 13. 14. 15. 16. 17. 19 19 19 19 19 19 28,30 19 26 23 23 23 23 23 23 5,13 23 16 areas are not used for storage purpose. It is required that the peeling wallpaper in the bathroom is replaced. It is required that the bathtub in the upstairs bathroom is cleaned. It is required that the sink in the upstairs bathroom is cleaned. It is required that the downstairs toilet is dusted. It is required that the curtain is re-hung in bedroom 7. It is required that the base of the bed in bedroom 7 is replaced as it is worn away. It is required that the home ensures that another hoist is purchased as soon as possible. It is required that the downstairs wall on the left of the lift is repaired. It is required that problem of offensive odour in a number of areas within the home is dealt with. 01/06/05 Immediate Immediate Immediate 30/05/05 01/06/05 01/06/05 01/06/05 Immediate 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 Good Practice Recommendations Westwood House C51 S31586 Westwood V226177 050505.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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