Inspection on 07/07/05 for Westwood Park

This inspection was carried out on 7th July 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westwood Park 18/01/10

Westwood Park 27/10/09

Westwood Park 20/01/09

Westwood Park 23/01/07

Westwood Park 08/11/05

Westwood Park 07/12/04

Westwood Park 17/08/04

Westwood Park 03/03/04

Westwood Park 19/11/02

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Westwood Park 4 Langholm Close Beverley East Yorkshire HU17 7DH Lead Inspector Diane Wilkinson Unannounced 7 July 2005 10:15 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 Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Westwood Park Address 4 Langholm Close Beverley East Yorkshire HU17 7DH 01482 862170 01482 887860 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) Londesborough Health Care Limited Mrs Kathleen Mary Monica Foley Care Home 51 Category(ies) of OP Old Age (51) registration, with number DE(E) Dementia - over 65 (51) of places Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th December 2004 Brief Description of the Service: Westwood Park is a privately owned care home that is registered to accommodate and care for 51 older people, including those with dementia. The company own another care home in a nearby town. Private accommodation is provided in 47 single rooms and two shared rooms, and there are various communal rooms available. The home is close to local amenities such as shops, banks, cafes, public houses and transport facilities. All areas of the home are accessible to service users via the provision of a passenger lift, a stair lift and ramps. The garden has been specially designed for the service user group and is attractive and easily accessible. There is a small car park available for visitors and staff. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours, including 1 hour’s preparation time prior to the inspection. The inspection included a tour of the premises and examination of documentation, including care plans. The inspector spoke to the registered provider, staff, relatives and several service users (including three on a one to one basis). What the service does well: 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 Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 6 contacting your local CSCI office. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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 Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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) 3 Service users are assessed prior to any decision being made about admission to the home and are only admitted to the home if it is felt that their care needs can be met. EVIDENCE: The records for a newly admitted service users were examined by the inspector. These evidence that an assessment of care needs was undertaken by staff at the home and that this assessment formed the basis of an individual care plan. The registered manager informed the inspector that service users are visited in their own home or in hospital prior to admission being agreed to, whenever this is possible, and that the assessment process commences at this stage. Service users and/or relatives are invited to visit the home prior to making a decision about admission, and some service users initially have respite care at the home until they make a decision about permanency. There is evidence that some relatives are involved in informing the home about important aspects of their relatives care needs, and that this is part of the assessment process. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 9 Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 11 There are systems in place to ensure that a service user’s individual care plan is reviewed regularly, ensuring that current care needs are met. Records examined and discussion with service users and relatives evidences that identified care needs are met by staff at the home. There is evidence that deteriorating illness and death are dealt with sensitively by staff and that changing needs are met. EVIDENCE: A new care plan format has been introduced at the home and care plans are in the process of being rewritten. New care plans include details of the strengths and needs of service users and the support that is needed by staff. There is documentation in place to record personal histories, lifestyle choices, physical dependency levels (including risk assessments) and very detailed moving and handling risk assessments. Monthly summaries of the care plan are recorded and these are signed by service users or relatives to evidence their involvement. Nutritional screening takes place and a separate record is kept of visits from health professionals, including the reason for the visit and the outcome. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 11 Pressure care and continence care is recorded appropriately, and there is evidence that appropriate equipment is provided. Risk assessments record the likelihood of pressure care being an area of concern. Policies and procedures in place on death and dying include information on palliative care, the involvement of family and friends in a person’s care and the need for privacy and dignity to be maintained at all times. The registered manager and another staff member have attended a course on death and dying and have started to cascade this training to the whole staff group. Relatives expressed satisfaction with the sensitive way in which care is offered to service users with deteriorating health and said that they are kept well informed of events concerning their relative. Records include a service user’s wishes in the event of their death. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 13 Service users are supported and encouraged to maintain their chosen lifestyle and to continue with chosen interests following admission to the home. Service users are encouraged and supported to make informed choices. EVIDENCE: Visitors were seen in the home on the day of the inspection – most service users have their own room or there are private lounge areas where service users can meet visitors in private. Care plans record the hobbies and interests of a service user prior to their admission to the home and lifestyle choices are recorded. Some service users are taken out by friends and relatives, and service users are encouraged and supported to maintain interests and hobbies. One service user helps with gardening at the home. Daily records include details of visitors seen and any activities taken part in. Service users confirmed that they choose what time to get up and go to bed. One service user said that she sometimes decides to watch a ‘late’ film and does not go to bed until it has finished. Service users can choose whether to take meals in one of the dining rooms or in their own room. There are various lounge areas in the home and service users can choose where and how to spend the day. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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 & 18 The home has a satisfactory complaints system with evidence that service users and others feel that their views are listened to and acted upon. Service users are protected from abuse by robust systems and policies and procedures that are understood by staff. EVIDENCE: There is an effective complaints procedure in place and a complaints log is used to record any complaints made to the home. The complaints log records the nature of the complaint, the action taken and the outcome. The complaints log is signed by the registered provider or registered manager as well as the complainant at the conclusion of the complaint. The inspector examined the complaint’s log and identified that the recorded complaints had been dealt with effectively and within given timescales. Service users stated that they know how to use the complaint’s procedure but have not had the need to do so. A recent training session has been arranged for staff on the protection of vulnerable adults from abuse, and managers at the home have attended Manager’s Awareness training. There are appropriate policies and procedures in place. There have been no reported allegations or incidents of abuse at the home since the last inspection. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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, 24 & 25 The home is well maintained and provides a safe environment for service users. Bedrooms have been personalised by service users to an extent chosen by them. The provision of locks and keys for bedroom doors and a lockable storage facility would enhance privacy for service users. EVIDENCE: The home provides comfortable, homely and attractive accommodation for service users. The home is well maintained and there is a refurbishment and maintenance programme in place. Furnishings and décor are comfortable, domestic in nature and of good quality. The garden area is accessed via the rear conservatory and is adjacent to the Beverley Westwood. Service users are able to choose the items of furniture that are provided for their bedroom, and a record is kept of a service user’s own possessions that are brought into the home. Some rooms have not been provided with a bedside light due to the health and safety risk to service users. Service users Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 15 should be provided with an alternative means of ‘low’ lighting, such as an ‘over bed’ light. There should be locks on all bedroom doors so that service users can be offered a key, and lockable storage should be provided in all bedrooms to enable service users to safely hold medication, valuables and money. Rooms are centrally heated and heating can be controlled in each room, and radiators are now guarded to control the risk of burning. All bedrooms have access to natural light and fresh air. The water system has been tested to detect the presence of Legionella in the water system and the result was negative. The inspector did not check the records of water temperature tests on this occasion but will do so at the next inspection. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 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 The staff rota evidences that there are sufficient skilled staff on duty to offer consistency of care to service users living at the home. Current NVQ training achievement evidences that staff are suitably qualified to meet the care needs of service users. The home’s recruitment and selection policies and practices fully ensure the safety of service users. EVIDENCE: Staffing levels are a reflection of the needs of the current service users. The staff rota records the role of each staff member, and includes a record of night staff, domestic staff and catering staff. There are three night staff on duty each night. There is a mix of experienced and newer staff employed at the home and training records evidence that they have the skills and experience to meet the care needs of service users. Eight care staff have achieved NVQ Level 2 or 3 in Care and another two care staff have enrolled for this training programme – the home is therefore on target to meet the 50 training requirement by the end of 2005. Recruitment and selection records examined by the inspector evidence that two written references and a satisfactory CRB check (or POVA first check) are obtained prior to staff commencing work at the home. Applicants complete an application form and this includes details of a person’s employment history. Staff induction takes place during the period between the interview and the start date, so that staff are ready to start work when their documentation is Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 17 received. A copy is retained of a person’s identification such as birth certificates, and of any training certificates held by applicants. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 18 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, 37 & 38 The home is well managed by an experienced and competent manager. The home maintains all of the records that are needed to safeguard service users. There are robust arrangements in place at the home protect the health, safety and welfare of service users. EVIDENCE: The registered manager and the registered provider are undertaking NVQ Level 4 in Management and have almost completed the full award. Both are registered nurses. There is evidence that both keep their practice up to date – the registered manager has recently attended death and dying training and an intermediate food hygiene course. There are clear lines of accountability at the home and the registered manager is responsible for only one home. The home maintains all of the records that are required by regulation, and there is evidence that service users have access to their records and opportunities to agree entries made. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 19 The registered persons provide a written statement of the policy, organisation and arrangements for maintaining safe working practices, including appropriate risk assessments. The passenger lift, stair lift and hoists have been serviced recently and the electrical installation was tested in November 2003 and is not due to be tested again until 2008. In-house fire tests/drills take place every two weeks (on the day shift and the night shift) and emergency lighting is also checked by staff. The fire alarm system was checked by a qualified contractor in March 2005, and there is a fire risk assessment in place. There is evidence that staff undertake health and safety training on an ongoing basis and that there are relevant policies and procedures in place. The inspector did not check the records for portable appliance tests or accident records but will do so at the next inspection. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 20 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 2 3 x STAFFING Standard No Score 27 3 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x 3 3 Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? Yes - this is now a recommendation 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 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. 1. Refer to Standard 24 Good Practice Recommendations Doors to bedrooms must be fitted with locks and service users must be offered a key. Lockable storage must be provided in all bedrooms. If bedside lights are not provided, an alternative form of low lighting must be provided. Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. Extracts may not be used or reproduced without the express permission of CSCI Westwood Park J53_s19737_Westwood Park_v228610_070705_Stage 4.doc Version 1.40 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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