Inspection on 08/11/05 for Westwood Park

This inspection was carried out on 8th November 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 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 Park 18/01/10

Westwood Park 27/10/09

Westwood Park 20/01/09

Westwood Park 23/01/07

Westwood Park 07/07/05

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 Ann Day Unannounced Inspection 8th November 2005 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 Park DS0000019737.V262199.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 Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westwood Park Address 4 Langholm Close Beverley East Yorkshire HU17 7DH 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) 01482 862170 01482 887860 Londesborough Health Care Limited Mrs Kathleen Mary Monica Foley Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51) of places Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 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 DS0000019737.V262199.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 over one day, 6 hours on 8th November 2005 with 2 hours preparation. Case tracking was employed as an inspection tool, which involves following the experience of a sample of service users and assessing the service they receive. An accompanied tour of the building was undertaken. Service users, the registered manager, proprietor and members of staff were interviewed, and documentation was examined. What the service does well: What has improved since the last inspection? What they could do better: Medication handling and administration recording was generally good, however, not all administration of medication was accurately recorded. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 6 It is recommended that risk assessments, are undertaken for all residents for the provision or non-provision of new locks and keys. 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 Park DS0000019737.V262199.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 Park DS0000019737.V262199.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): 2,3,5,6 Service users are assessed before admission to the home, and they and their relatives are given the opportunity to visit the home prior to taking up residence. Service users are provided with a written contract/Statement of terms of conditions of the home. EVIDENCE: Each care record examined contained a detailed and comprehensive assessment of needs, a social services care plan, and a biographical assessment, including a physical assessment. Care records contained a signed contract/statement of terms and conditions with the home. 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. The home does not provide intermediate care. Westwood Park DS0000019737.V262199.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): 7,8,9,10 Service users health care needs are fully met; their health, personal and social care needs are set out in an individual care plan. Service users are treated with respect and their dignity is upheld. However, service users safety would be better protected by the improvement in the home’s recording of the administration of medication. EVIDENCE: Care records detail 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. Members of staff were seen knocking on bedroom doors and awaiting an invitation before entering. The manager and staff were seen to have good relationships with the residents, and residents commented, “All the staff are very nice, I am pleased I found this home, I feel comfortable”. “Happy people who treat me well”. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 10 Medication handling and administration recording was generally good, however, not all administration of medication was accurately recorded. This was brought to the attention of the registered manager and the proprietor, who was able to give the assurance that inaccuracies and omissions would be resolved with the care staff concerned within seven days. Local pharmacist has visited the home on a regular basis in the past, and this arrangement is to be reinstated in the near future. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15 Service users are provided with the opportunity to engage in a variety of activities, satisfying their social, cultural and religious needs. Service users maintain contact with family and friends as they wish; they are helped to exercise choice and control over their lives; and they receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: Service users and members of staff confirmed that the home’s activity programme is varied, they described the recent bonfire night party, and outings and events were advertised on the home’s notice board. One resident was busy, making clothes for African children and her care plan evidenced her membership and involvement with a local church and charitable projects. The mobile library visits the home regularly and several residents said how much they enjoy access to varied reading material. Residents commented on outings they were enabled to take with their relatives, such as shopping and to see “The Cottingham Singers”. All residents consulted confirmed that, their relatives are, made very welcome by the manager and the staff. One resident said that, “relatives are made welcome and always offered a drink”. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 12 Service users confirmed that they choose what time to get up and go to bed. The residents were observed having their midday meal, which was hot, appetising and well received. Residents were able to take their meal in one of the two dining rooms or in their own room, as they wished. Residents’ comments about the food provided was generally very positive, however one service user commented, “Food not as good as it used to be”; and another said, ”Food is alright, sometimes it can be a bit cool, but today’s was lovely and hot”. Environmental Health Officer visited on 8.6.05 and found the premises satisfactory. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 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 the following standard(s): 16,18 Service users are protected from abuse; and they and their relatives can be confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: The home has a comprehensive complaints policy and procedures. Service users and members of staff said that they would have no hesitation in raising any concern with the manager, in the knowledge that she would treat their concerns seriously. Residents spoken to had no complaints about the service; one resident said, ”I have nothing to grumble about;” another resident said, “I could go to Kate, she is a very nice lady, there is nothing I would change”. On the day of the inspection the management of the home were meeting with representatives of the Primary Care Trust to address a concern, which had been raised by one of the home’s staff. Members of staff have attended training on the protection of vulnerable adults from abuse, and the manager of the home has 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 DS0000019737.V262199.R01.S.doc Version 5.0 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 the following standard(s): 19,23,24,25,26 Service users live in a safe, well-maintained, clean environment, with their own possessions about them. 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’ rooms are individually decorated and furnished; and a record is kept of, each service user’s 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, alternative low lighting has been provided. A number of service users have been provided with locks and keys to their rooms, and locked storage on request. All rooms are fitted with key locks, on a master key system and privacy/penny locks, which can be overridden. Service users and relatives have been approached about the provision of new locks Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 15 and keys and a number have had risk assessments completed where a decision has been made not to provide new locks and keys, in the interests of the individual service user’s safety. All residents should have a risk assessment completed with regard to the provision or non-provision of new locks and keys. Rooms are centrally heated and heating can be controlled in each room, and radiators are 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. Water temperatures are regularly tested and the records were made available for inspection. The home employs two domestic cleaners and a part time laundry worker, the home is clean and tidy and free from malodour. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 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 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): 27,28,29,30 Service users’ needs are met by sufficient competent and trained members of staff, and are protected by the home’s recruitment policy and practices. EVIDENCE: Sufficient numbers of staff were on duty on the day of the inspection to meet the needs of the current 46 residents of the home. The proprietor confirmed that staffing is adjusted to meet the needs and numbers of service users in the home. One concern was expressed about staffing levels at the home and this was pointed out to the proprietor. The home has robust recruitment policies and procedures in place; staff files examined all contained, records of induction, terms and conditions, Criminal Records Bureau (CRB/POVA) checks; all bar one had application forms, interview records and two written references. This one staff file had documented transfer under TUPE and the retention of these documents by Social Services Department. The home benefits from the skills of four Bulgarian trained nurses, who are working as care assistants, in addition to the registered manager and the proprietor who are registered first level nurses and an enrolled nurse who works on night duty. The proprietor and registered manager confirmed that the home meets the target of 50 care staff to have achieved NVQ Level 2 or equivalent. One member of staff has achieved NVQ Level 3 and two members of staff are currently undertaking NVQ Level 3. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 17 The home has a training and development programme in place. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 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 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): 31,33,36,37,38 Service users benefit from a home that is well managed, their health, safety and welfare and that of staff is promoted and protected. Members of staff are appropriately supervised, and service users’ best interests are safeguarded by the home’s record keeping, policies and procedures. EVIDENCE: The registered manager and the registered provider are undertaking the Registered Managers Award. Both are registered nurses. 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. Staff files contained regular supervision and appraisal records. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 19 The home has in place all policies and procedures required by regulation. The passenger lift, stair lift and hoists have been serviced regularly and the electrical installation servicing documentation was available for inspection. The fire alarm system checks had been undertaken and there is a fire risk assessment in place. PAT testing of electrical equipment had been undertaken as per the regulations. There is evidence that staff undertake health and safety training on an ongoing basis and that there are relevant policies and procedures in place. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 Standard No Score 16 3 17 X 18 3 3 X X X 3 3 3 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 X 3 3 3 Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 21 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 OP9 Regulation Reg. 13(2) Requirement The administration of medication must be accurately and consistently recorded. Timescale for action 15/11/05 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 OP24 Good Practice Recommendations Risk assessments for the provision or non-provision of new locks and keys should be undertaken for all residents. Westwood Park DS0000019737.V262199.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000019737.V262199.R01.S.doc Version 5.0 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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