CARE HOMES FOR OLDER PEOPLE
WESTY HALL Marsden Avenue Latchford Warrington WA5 1UB Lead Inspector
David Jones 7 and 9
th th Unnnounced July 2005 10:07 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. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Westy Hall Address Marsden Avenue Latchford Warrington Cheshire WA5 1UB 01925-637948 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) CLS Care Services Limited Janice Johnson Care Home 39 Category(ies) of OP - Old Age - 29 registration, with number DE(E) - Dementia - over 65 (10) of places DE - Dementia (2) WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The home is registered for a maximum of 29 service users to include: * Up to 29 service users in the category of OP (old age not falling within any other category). * Up to 10 service users in the category DE(E) (dementia over the age of 65) may be accommodated. * Up to 2 service users in the category DE (dementia over the age of 55) may be accommodated. 2 The registered provider must, at all times, employ a suitably qualified an experienced manager who is registered with the Commission for Social Care Inspection. Service users with dementia shall only be accommodated within the designated dementia care section of the establishment. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection. 13 December 2004 3 4 Date of last inspection Brief Description of the Service: Westy Hall is a care home, which is in located Latchford, a residential area of Warrington. It is close to bus routes, local shops and other public amenities. It is registered with the Commission for Social Care Inspection to offer personal care for up to 39 older people. The home is divided into two parts. One part of the home provides personal care for up to 29 older people whose needs are associated with old age and the other section of the home provides for ten older people with a diagnosed dementia. Two of the residents accommodated on the dementia unit may be 55 years of age or older. It is owned and managed by CLS Care Services Group. The premises is a purpose built twostorey property with access to the second floor provided by one passenger shaft lift and three stairways. Accommodation includes 39 single bedrooms, all having hot/cold water washbasins and door locks fitted. Communal facilities include five separate lounge areas, two dining rooms, one smoking room and one quiet room. There are four bathrooms, one shower room and 12 WC’s. There are also kitchen and laundry facilities on the ground floor, and the home has its own “hairdressing salon”. The home is set within its own grounds and residents have access to internal gardens. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit was a routine unannounced inspection. It took place on two days, the 7th and 11th of July 2005, over a 9-hour period. Nine residents and five members of staff were spoken with during the inspection. We looked at some parts of the building, inspected medication systems, looked at some records and read the case notes of four residents. What the service does well:
Westy Hall is well managed and run in the best interests of residents. Residents speak highly of the home and the standard of care and facilities and services provided. Accommodation is comfortable, well equipped and nicely decorated. The admission procedures make sure that residents and their representatives are aware that the home can meet their needs before they move in. The home’s care planning systems are based on good practice. They make sure that residents’ needs are known and planned for. Senior staff work closely with other health and social care professionals and residents are assured that there health care needs will be addressed. The atmosphere in the home is sociable and visitors are made welcome. Residents are able to choose from a number of activities and are assisted to visit the local shops and other places of interest. All stated that the standard of catering was good. Choice was offered with every meal, and likes, dislikes and special dietary needs were known and catered for. There is a skilled and dedicated team of staff who were seen to be caring and considerate in their approach. There is an effective staff training and development programme in place. More than 50 of the care staff team had acquired or were studying for an NVQ in care at level two or above. Staff are unanimous in their support for the manager who provided leadership direction and support. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 6 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.
WESTY HALL F51 F01 S27014 Westy Hall V235655 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 WESTY HALL F51 F01 S27014 Westy Hall V235655 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) 2, 3, 4 and 5. New residents are admitted to the home on the basis of a full assessment undertaken by persons with appropriate training. Assessment and admissions procedures put the new resident and their representatives at the centre of decision-making. They receive written confirmation that the home is suitable to meet their needs and are able to visit the home before they make any decisions about moving in. EVIDENCE: Reading of the case records confirmed that the home used appropriate assessment and admissions procedures that involved the new resident and their representatives. This put the resident at the centre of decision-making. All new residents had their needs assessed by the placing agency or by senior staff before moving in. A letter on a resident’s case file confirmed that new residents were able to meet with senior staff to discuss how the home would meet their needs before they moved in. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 9 A resident who had recently moved in said Westy Hall is very good for her. She felt secure in the home and spoke highly of the staff stating that they treated her with respect. She said “staff are not like bosses they treat us as equals. They are there when you need them and we rely on them for support. There were no rules other than those put in place for your safety. Residents were able to get up and go to bed at the times they preferred and those who were able could come and go when they pleased. They were only asked to let staff know when they would be back”. This resident had seen and signed her care plan. She was very clear as to how the home was meeting her needs. WESTY HALL F51 F01 S27014 Westy Hall V235655 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, 9, and 10.The home’s assessment and care planning systems ensure that residents’ identified and developing needs are met. Risk assessment and prevention of falls procedures require further development to make sure that risks of falling are minimised. The home works closely with other health and social care professionals and residents are assured that their health care needs will be addressed. Arrangements for the storage, recording and administration of medication require improvement to ensure the protection of residents. EVIDENCE: Four care plans were read as part of a case tracking exercise. The home’s care planning processes are based on good practice. Discussion with residents and staff indicated that residents are involved with the development of their care plans and arrangements for care and support are developed according the individual’s needs, interests and preferences. Some residents had signed their care plans. It was positive to note that independence and residents’ rights to privacy and respect are promoted in the way staff supported residents with daily routines. In each case the care plan provided confirmation as to how a broad range of needs were being met and included details of what the resident could do for themselves.
WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 11 Senior staff stated that a concerted effort had been made since the last inspection to ensure that care plans were reviewed and updated appropriately. One resident spoken with had suffered an un-witnessed fall and cut the bridge of her nose and bruised the whole of her face. The care plan and risk of falls assessment had not been updated since the fall. A note in the general message book indicated staff had considered what had caused the resident to fall. They thought that it could have been the heels on her shoes. A note in the message book said the resident should not wear her heeled shoes. This information had not been transferred to the care plan to make sure that all staff followed this advice. The resident had diabetes. Records indicated that the District nurse monitored blood sugar levels on a regular basis but the last recorded check was dated two weeks before the fall. The District nurse or the GP had not been contacted regarding the fall and there was nothing to suggest that staff had considered whether her diabetes or her medication were possible factors. Senior staff said that the resident had deteriorated in her mobility but extent of the deterioration was not recorded in the risk assessment and there had been no referral to the occupational therapist. See requirement 1. Records seen and discussion with senior care staff indicated that there were good working relations with local health and social care professionals. Senior staff took immediate action to address the possible health care issues identified during the inspection and contact was made with the GP and a referral was made to the occupational therapist. This is commendable. The National Institute for Clinical Excellence has produced guidance on the prevention of falls in relation to older people. It is recommended that a copy of this is obtained for the guidance of staff and the prevention of falls in the home. See recommendation 1. The home’s medication systems were checked by random sampling. Errors were identified in the administration of controlled drugs, which appeared to have been recorded as given on two days but the tablets had remained in the Monitored Dose System (MDS) card. Further examination indicated that the medicines had been given but taken from the wrong section of the MDS card. See requirement 2. WESTY HALL F51 F01 S27014 Westy Hall V235655 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) 12,13,14 and 15. The lifestyle in the home reflects the expectations and personal preferences of residents and choice is promoted. Visitors are made welcome, the standard of catering is good and residents have access to a range of appropriate activities. EVIDENCE: The atmosphere in the home was relaxed, pleasant and sociable. Residents on the dementia unit were enjoying the garden and were involved in a number of other activities including board games and domestic routines. The home employs an activities co-ordinator and a number of activities were on offer including arts and crafts. Residents said they enjoyed the activities including the escorted outings to local shops and places of interest. The standard of care, facilities and services were said to be good. Residents spoke highly of the staff team telling that they were treated with respect and their rights to make choices were supported and promoted. Visitors were made welcome. All praised the standard of catering. A Residents’ Survey had been completed as part of the home’s quality checks which, included requests for feedback on the quality of meals provided. The menu offered a varied and nutritious diet and special dietary needs were catered for. WESTY HALL F51 F01 S27014 Westy Hall V235655 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 and 18. Arrangements for the protection of residents and for making complaints were effective. EVIDENCE: The home’s complaints procedure provided appropriate guidance and information as to how to make a complaint. Information provided indicated that no formal complaints had been received since the last inspection. A comments book recorded a number of minor complaints, which had been attended to, and a higher number of compliments made by residents and visiting relatives. A record is maintained in the home of all complaints made and includes details of the investigations and any action taken as a result. Robust procedures for responding to suspicion or evidence of abuse or neglect were in place including whistle blowing as in accordance with the Public Interest Disclosure Act 1998. The manager said all staff had received a booklet providing guidance on the implementation of adult protection procedures. Further training needs identified via the home’s staff appraisal systems would be addressed in due course. WESTY HALL F51 F01 S27014 Westy Hall V235655 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. 22 and 26. residents live in well-maintained, comfortable, clean and hygienic accommodation with access to appropriate indoor and outdoor communal facilities. EVIDENCE: Westy Hall is located in Latchford, a residential area of Warrington with easy access to the local shops and general amenities. The home is well maintained with good quality furnishings and fittings. It is set within its own grounds and there is an internal garden, which has been divided to provide a safe enclosed area for people with dementia. Residents spoke highly of the home and stated satisfaction with facilities and services provided. The home was found to be clean and hygienic. The home has four bathrooms that have been designed to meet the needs of people with mobility problems. All bathrooms were in good working order. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 15 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 and 30. Staff were employed in appropriate numbers and skill mix sufficient for the well being of service users. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 16 EVIDENCE: Information provided by the manager and worked rotas seen during and after the inspection confirmed that staff were employed in following numbers: 1. The main part of the home. • • 2. a minimum of 3 and on occasion 4 and 5 members of care staff including a Care Team Leader were on duty 8am to 3pm. a minimum of 3 members of staff including a Care Team Leader were on duty in the afternoons and evenings from 3pm to 10pm. The 10-place Dementia Unit: • A minimum of 2 members of care staff including one Care Team Leader was on duty throughout the day from 8am-10pm. The employment of staff in the Dementia Unit did not reflect the numbers of staff agreed with the registration authority prior to the registration of the home to accommodate up to 10-service user with dementia. These are indicated as follows: • A minimum of two members of care staff rostered on duty between the hours of 8am and 10pm inclusive of a care team leader and in addition two five hour shifts to be worked flexibly between the hours of 8am and 10pm. And two members of staff on wakeful night duty between the hours of 10pm and 8am. The manager and staff said they were of the view that the current staffing levels were appropriate to meet the assessed needs of the residents. We did not see any evidence to contradict this on the day of the visit. The manager said staffing levels are monitored and are raised when residents’ needs change. Information provided by the manager indicated that five of the 25 members of care staff had achieved an NVQ in care to level two or above and a further ten were working towards the qualification. When 13 have this qualification the standard regarding at least 50 of the home’s care staff team achieving an NVQ level 2 in care will be met. See recommendation 2. Training records provided by the manager indicated that CLS continue to operate a comprehensive staff-training programme that had been developed to incorporate “Skills For Care” staff training standards. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 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) 33 and 36. Progress had been made in implementing the home’s quality assurance procedures and there is clear evidence that the home is well managed and run in the best interests of service users. EVIDENCE: Progress had been made toward meeting the requirement made at the last inspection to establish a system for reviewing and improving the quality of care in the home. A system for assessing the quality and content of care plans had been introduced and the manager had introduced a “residents’ and a relatives” satisfaction questionnaire. Information from the returned questionnaires had been put together in a report that is open to the public. It is recommended that the home also asks other stake-holders including visiting health and social care professionals about quality of care and develops the report to confirm action taken to address quality issues raised by residents and other interested parties. See recommendation 2. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 18 All staff were supervised as part of the normal management processes of the home. Staff spoken with during the inspection said that a programme of formal supervision had been started. All senior staff had had at least one session of supervision and arrangements were made to ensure that all care staff were offered supervision at the appropriate frequencies. Staff were unanimous in there support for the manger who was held in high regard. Morale was said to be buoyant. There was a sense of teamwork amongst the staff group. Staff said that they had benefited from straining opportunities including “Dementia Care” which had given them insight and a better understanding of meeting the needs of people with dementia. One senior member of staff said that she had benefited from assertiveness training, which had helped her to delegate duties to other staff in a supportive and positive manner. It was evident that the management approach to the home had created an open and positive atmosphere. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 19 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x x WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 20 yes 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 OP8 Regulation 12 and 13 Requirement The registered persons must review risks of falls assessments when residents’ circumstances change and, where necessary, must make contact with relevant health care professionals in the interests of preventing falls. The registered persons must ensure that controlled drugs are administered and recorded in accordance with the requirements of the regulations and the National Minimum Standards. Timescale for action 30/07/05 2. OP9 13 and 17 30/07/05 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 OP7 Good Practice Recommendations The registered persons should acquire a copy of the National Institute for Clinical Excellence “Guidance for the Prevention of Falls in Older People” for the guidance of care staff. The registered persons should ensure that at least 50 of the care staff team achieve an NVQ in care at level 2 or above.
F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 21 2. OP28 WESTY HALL 3. OP33 The registered persons should conduct a survey that asks visiting health and social care professionals about quality of care in the home and develop the quality assurance report to confirm action taken to address quality issues raised by residents and other interested parties. WESTY HALL F51 F01 S27014 Westy Hall V235655 070705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich Cheshire, CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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