Care Home: Westbury Nursing Home

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What the care home does well The Westbury is owned by a provider who is prepared to put much effort into service improvements, who ensures that if we identify matters which need to be addressed, they develop clear improvement plans, to ensure that deficits service provision are addressed. The provider is prepared to invest in a wide range of areas to meet resident need. The home has clear, established documentation systems to ensure that full assessment of need are made prior to a person being admitted. After admission, the home has full systems for ensuring that plans of care are in place to meet resident need. Monitoring systems for care provision are effective. The home is welcoming in atmosphere. This is supported by the administrator, who greets visitors in a helpful and supportive manner. The new manager has an open door policy and we were able to observe during the inspection that people felt able to come and talk to then about matters of concern to them or just for a chat. The home has an enthusiastic activities person who is prepared to work very flexibly to meet different peoples needs. The chef has further developed the meals service and the quality of meals is shown by the fact that many of the people in the home show improvements in their weight, since they have been admitted. Nursing and care staff are supportive of meeting residents` needs. For example we observed a care assistant discussing with a resident about when they wanted to get up and supporting the resident in choosing when they did get up. The home has a maintenance man who works with all the other staff and is keen to provide a effective supports to residents. People expressed their appreciation of the home in the questionnaires. One person reported that staff in the home "listens, acts on information given, positive or negative, creates a happy relaxed environment for residents/relatives", another "the overall quality has greatly improved with the arrival of a new home manager. Spirits are lifted and atmosphere great" and another "the staff always do their best, even under pressure, they are very caring; some are excellent at their job". A member of staff commented "the Westbury has become a vibrant place to work. The residents notice an uplifting mood". People also commented on the home to us during the inspection. One person reported "everybody`s very nice and helpful", another "I couldn`t wish for better" and another "everyone is happy here". What has improved since the last inspection? The home has improved across a wide range of areas since the last inspection. At the last inspection, 23 requirements were identified and 17 good practice recommendations made. All had been addressed in full by this inspection. A new manager, deputy manager and administrator have been appointed. The new manager is highly experienced and has a track-record of making improvements in services. The home has revised and developed its information systems for people. Staff working in the home also report they feel fully informed about prospective residents` needs. Improvements have been made in assessments of need, particularly social care needs, so that all information about a person`s past life is more available to staff, when planning care after a person has been admitted. The home has much improved its care planning processes, ensuring that plans conform to national guidelines and research-based evidence. As a result no residents currently cared for in the home have developed pressure ulceration whilst in the home. Other improvements include care plans for topical applications prescribed for residents and information on the use of urinary catheters. The home has ensured that residents can now exercise choice in their daily lives and are supported in maintaining and developing their independance whilst in the home. The activities person is now more supported in their role, so that residents who wish to can more easily participate in activities when they wish to. Improved links have been developed with residents` relatives and records are maintained to inform staff of when relatives have been advised of matters about their relative. A full review of the meals service has taken place, with development of menus and improvements in service to people who need all support to eat their meals. The new manager has fully reviewed the systems for complaints, making sure that they investigate all matters in full and take action where indicated, including informal complaints and concerns. Staff have been trained in abuse awareness and those spoken with were fully aware of their responsibilities for safeguarding vulnerable people. The provider has reviewed its some of its commonly used equipment and replaced such items, including bed rail protectors and sanitary items. The provider has invested in additional equipment to meet the disability needs of people, particularly provision of chairs for people with complex seating needs. Improved systems have been put in place to prevent risks to people from communal use of topical creams. Sluice rooms have been improved and the maintenance man was in the process of developing plans for them to be further improved. Staffing levels have been reviewed and the home has managed to cease using agency staff, apart from the very odd occasion. A full review of staff files has been undertaken and now had all required information on them, to ensure that people were protected by safe recruitment systems. The provider has ensured that the home are now complying with its polices and procedures on induction, so that staff are fully supported when they commence their role. The home has ensured that staff have now received training, so that they can be able to perform their role in a safe and knowledgeable manner. Systems for supervision of staff have been established. The home has much developed its systems to ensure the health and safety of people. Including reviews of risk assessments, ensuring safety when bed rails are used, further developing security of the home and ensuring that the principals of fire safety are upheld. Staff have been supported in this by training in areas relating to health and safety, including manual handling practice and fire safety. What the care home could do better: No requirements were identified at this inspection. A few areas relating to improving the detail of care plans were advised. These included always ensuring that where people where prescribed thickening agent that the required consistency of the drink for the resident be recorded and that the actual diet given, rather just that a person had been given a "soft" diet be documented. The home were advised to expand its evaluations when residents were prescribed medicines which could affect their daily lives, so that the benefits or other of prescribed medication be identified. Provision of further disposable glove dispensers were advised. Supervisions, now that they have been established, need to be further developed, with more observed practice and one-to-one supervisions. We are pleased that the new manager and her staff have successfully improved service provision in this home. We are aware that much change has taken place in a short space of time. We have advised the manager that we reserve the right to re-inspect the home if we are notified that they leave the home, to ensure that the improvements show at this inspection, have been sustained. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Westbury Nursing Home 86 Warminster Road Westbury Wiltshire BA13 3PR     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susie Stratton     Date: 2 8 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Westbury Nursing Home 86 Warminster Road Westbury Wiltshire BA13 3PR 01373825868 01373825013 Telephone number: Fax number: Email address: Provider web address: www.bupa.co.uk Name of registered provider(s): BUPA Care Homes (CFC Homes) Ltd care home 51 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The staffing levels set out in the Notice of Staffing dated 9 January 2004 must be met at all times. This can be reflected in the Statement of Purpose. Date of last inspection Brief description of the care home The Westbury Nursing Home is registered for 51 people. The building was purposebuilt as a care home and opened in December 1993. Accommodation is provided over two floors, with a passenger lift in-between. The home aims to meet the needs of frail, elderly people, those with a physical disability and those who need care in the terminal stages of life. It also offers respite care for people living in the town of Westbury. A new manager has been appointed since the last inspection. This person is to be assessed in accordance with our processes. A team of registered nurses, care Care Homes for Older People Page 4 of 35 Over 65 51 0 0 5 1 1 1 2 2 0 0 8 Brief description of the care home assistants, activities coordinator, adminstrator and ancillary staff are employed in the home. The Westbury is situated on the A350, leading into the small market town of Westbury. Car parking is available on site and a bus stop is situated close to the entrance. Westbury also has a main line railway station. The fee range is 650 pounds to 900 pounds per week. Items not included in the fees are hairdressing, chiropody, visitors meals, physiotherapy, newspapers and telephones. A copy of the service users guide is provided in each residents bedroom and a copy is also available in the main entrance hall. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 40 questionnaires were sent out and 19 were returned. Comments made by the people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered, including improvement plans sent in by the provider. We also received the annual quality assurance assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last six months. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. As the Westbury is a larger registration, the site visits took place over two days. Both Care Homes for Older People Page 6 of 35 the site visits were conducted by one inspector but this person is referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The first site visit was on Tuesday 19th May 2009 between 10:15am and 5:05pm. The second site visit was on Thursday 28th May 2009 between 10:05am and 11:15am. The first site visit was unannounced. The deputy manager was on duty for the first site visit. The prospective manager was on duty for the second site visit and was available for the feedback at the end of the site visits. During the site visits, we met with twelve residents and observed care for four residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day. We reviewed care provision and documentation in detail for six residents, across all parts of the home, one of whom had been newly admitted. As well as meeting with residents, we met with three registered nurses, five carers, the activities coordinator, the hotel services manager and the maintenance man. We observed a lunchtime meal and an activities group. We reviewed systems for storage of medicines and observed medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records and complaints records. What the care home does well: What has improved since the last inspection? The home has improved across a wide range of areas since the last inspection. At the last inspection, 23 requirements were identified and 17 good practice recommendations made. All had been addressed in full by this inspection. A new manager, deputy manager and administrator have been appointed. The new manager is highly experienced and has a track-record of making improvements in services. The home has revised and developed its information systems for people. Staff working in the home also report they feel fully informed about prospective residents needs. Improvements have been made in assessments of need, particularly social care needs, so that all information about a persons past life is more available to staff, when planning care after a person has been admitted. The home has much improved its care planning processes, ensuring that plans conform to national guidelines and research-based evidence. As a result no residents currently Care Homes for Older People Page 8 of 35 cared for in the home have developed pressure ulceration whilst in the home. Other improvements include care plans for topical applications prescribed for residents and information on the use of urinary catheters. The home has ensured that residents can now exercise choice in their daily lives and are supported in maintaining and developing their independance whilst in the home. The activities person is now more supported in their role, so that residents who wish to can more easily participate in activities when they wish to. Improved links have been developed with residents relatives and records are maintained to inform staff of when relatives have been advised of matters about their relative. A full review of the meals service has taken place, with development of menus and improvements in service to people who need all support to eat their meals. The new manager has fully reviewed the systems for complaints, making sure that they investigate all matters in full and take action where indicated, including informal complaints and concerns. Staff have been trained in abuse awareness and those spoken with were fully aware of their responsibilities for safeguarding vulnerable people. The provider has reviewed its some of its commonly used equipment and replaced such items, including bed rail protectors and sanitary items. The provider has invested in additional equipment to meet the disability needs of people, particularly provision of chairs for people with complex seating needs. Improved systems have been put in place to prevent risks to people from communal use of topical creams. Sluice rooms have been improved and the maintenance man was in the process of developing plans for them to be further improved. Staffing levels have been reviewed and the home has managed to cease using agency staff, apart from the very odd occasion. A full review of staff files has been undertaken and now had all required information on them, to ensure that people were protected by safe recruitment systems. The provider has ensured that the home are now complying with its polices and procedures on induction, so that staff are fully supported when they commence their role. The home has ensured that staff have now received training, so that they can be able to perform their role in a safe and knowledgeable manner. Systems for supervision of staff have been established. The home has much developed its systems to ensure the health and safety of people. Including reviews of risk assessments, ensuring safety when bed rails are used, further developing security of the home and ensuring that the principals of fire safety are upheld. Staff have been supported in this by training in areas relating to health and safety, including manual handling practice and fire safety. What they could do better: No requirements were identified at this inspection. A few areas relating to improving the detail of care plans were advised. These included always ensuring that where people where prescribed thickening agent that the required consistency of the drink for the resident be recorded and that the actual diet given, rather just that a person had been given a soft diet be documented. The home were advised to expand its evaluations when residents were prescribed medicines which could affect their daily lives, so that the benefits or other of prescribed medication be Care Homes for Older People Page 9 of 35 identified. Provision of further disposable glove dispensers were advised. Supervisions, now that they have been established, need to be further developed, with more observed practice and one-to-one supervisions. We are pleased that the new manager and her staff have successfully improved service provision in this home. We are aware that much change has taken place in a short space of time. We have advised the manager that we reserve the right to re-inspect the home if we are notified that they leave the home, to ensure that the improvements show at this inspection, have been sustained. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 10 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be supported by the information given to them about the services in the home. Residents will have full individualised assessments of need, so that the home can fully demonstrate that they can meet the persons needs. Evidence: The home has revised its information given to prospective residents since the last inspection. We observed that copies of the information was available in the entrance area, as well as each residents room. The information was clear and gave a wellrounded impression of the services provided by the home. Of the eleven people who responded to this section of the questionnaire, ten reported that they had received enough information about the home prior to admission. One person reported daughter looked around and all questions were answered. In their AQAA, the home reported that the provider performs regular mystery shoppers, so that they can assess if people are given the information that they need about the home. They also report that they actively advise people to look at other homes in the area, so that they Care Homes for Older People Page 12 of 35 Evidence: can contrast the services at the Westbury with other homes. During the inspection, we met with more than one resident who was able to tell us about their experience of being admitted to the home. One person described the very nice lady who visited them prior to admission. Another person described how they had been able to chose their room as to lay it out so as they wanted. In their AQAA, the home reported that they encourage people to visit the home prior to admission and allow for trial periods, so that the person can find out if the home suits them. One person described in their questionnaire how their spouse and another family member had been to visit the home before admission. The prospective manager reported that they advised people to make more than one visit before they reached a decision, including unannounced visits and weekend visits. This was confirmed by the deputy manager who reported that they had experience of showing people around the home at weekends. We discussed new admissions with staff. One carer informed us that they were always informed about people who were admitted and gave us an example of a person who had been admitted on a special diet and how they had been informed about this. The chef reported that they were always informed of new admissions and would go and meet them, to discuss their dietary needs and preferences. The activities coordnator reported that tried to meet with all new admissions promptly, including their relatives, so that they could get a clear picture of their past lives and interests. The home was last inspected only six months ago, so not many people had been admitted since then. We reviewed records relating to one newly admitted person. The provider uses a standard assessment tool, which provides trigger questions, to ensure that all areas relating to a persons nursing and care needs are included. When a need is identified, the tool directs staff on where a further assessment and/or care plans need to be developed. We observed that this persons pre-admission assessment had been completed in detail. The assessment noted previous medical conditions and how they were to be met. There was evidence from this persons records that certain aspects of their medical care had shown improvement since they had been admitted. Their preferences for how they would wish to spend their day was documented and the resident reported that this was respected by staff. Individual areas relating to communication needs were clearly documented and conformed in full to what we observed when we met the person. Staff we met with clearly knew this resident well and what they told us conformed to what was documented in the persons assessments and care plans. Staff also showed an awareness of how difficult it must be for a person to settle into a care home and that they could see that the person was Care Homes for Older People Page 13 of 35 Evidence: gradually coming to terms with this change in their life. The resident reported to us that staff had been very helpful to them while they were getting used to being in the home. Care Homes for Older People Page 14 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be supported by staff who are fully aware of how to meet their health and personal care needs. Care provision is supported by clear and detailed records, which staff follow when providing nursing and care. Evidence: This home has put much work into making improvements for people in relation to their health and care needs since the last inspection. In their AQAA, the home mentions a range of interventions, including regular audits of care provision and development of a key worker system, to ensure that outcomes for people have been improved in this area. Several people commented to us about nursing and care provision in questionnaires. One person reported about care provision this has improved with the new manager in the last month, another staff ask family and do listen and act accordingly and another have found everyone very helpful. During the inspection, people also commented to us about the home. One person said I get every attention. We observed that more people were being assisted to get up and dressed during the day than at the last inspection, rather than remaining in bed for the whole day. Care Homes for Older People Page 15 of 35 Evidence: We reviewed residents records and observed that, as stated in the homes AQAA, care plans were person-centered. Peoples nursing and care needs were assessed, including risk identification. Where a need or a risk, such as risk of pressure ulceration, falls or dietary risk was identified, a detailed care plan was drawn up to direct staff on how the need was to be met and/or the risk reduced. Care plans now all conform to local and national guidelines. The effect of this can be seen in relation to prevention of risk of pressure ulceration, where there was no longer evidence that people are developing pressure ulceration in the home. At the time of the inspection, the home only had one resident with a pressure ulcer and this had developed before the person was admitted. The home has clear documentation where people are not able to turn themselves or give themselves food or fluids. Monitoring charts provided evidence of compliance with care plans and we observed that they were completed at the time care was given. The home shows good practice across a range of areas. for example one person we met with needed thickening agent to assist them in swallowing, they told us that staff always put thickening agent in their drinks and their care plan reflected in full what the person told us. Another person had a very clear care plan in relation to their manual handling needs, this included reference to a specific need relating to ensuring the safety of one of their limbs. Another person who was being artificially fed by a tube had a clear care plan relating to care and cleaning of the tube site. This person was also allowed some food by mouth and their care plan clearly stated the amount and types of food that they should eat. Where a residents need had changed, their care plan was up-dated when relevant. Any changes were dated and signed. For example one persons personal care plan showed that they were being supported in increasing management of their own personal care and their care plan was up-dated as they became more independent, to state what actions they could now perform independently. Another residents records showed that they had requested a change of night care in relating to prevention of pressure ulceration. Their records showed how staff had worked with the person to ensure that their preference was met whilst still keeping risk of pressure ulceration to a minimum. Where a person had additional mental health care needs, care plans were developed, these were supportive in tone and non-judgemental language was used to describe the persons needs. This attitude was also reflected in the persons daily records, where staff wrote down how the resident had presented themselves and their actions to meet the persons needs. Care Homes for Older People Page 16 of 35 Evidence: We discussed nursing and care provision with staff. One person described shift handovers as comprehensive, another residents needs are now being met more, and another the overall quality has greatly improved with the arrival of a new home manager. All staff spoken with showed a detailed knowledge of residents and how to meet their needs. Several staff reported that now that they had received training in how to meet residents needs, they felt more aware of a range of matters in care provision. Staff reported on the good working relationship with external healthcare professionals, including the tissue viability nurse, speech and language therapist and dietitian, as well as local GPs. Residents records provided evidence of these working relationships, showing that the residents GP would be promptly consulted if their condition changed. For example, one persons night report documented that the resident had reported pain during the night, their day record showed that their GP was consulted that day and that a painkiller had been prescribed. Where a resident had a wound, there were clear records of the wounds response to treatment and consultation with the tissue viability nurse. A few areas only are recommended to to be considered. One resident was prescribed oxygen and was using nasal canulae. They had a clear care plan about their use of oxygen, however how often the nasal canulae should be changed was not documented. This is recommended as if a person has an infection, there is a possibility that they can be re-infected if such tubing is not changed regularly. One person who had a wound had their wound photographed regularly, which is regarded as good practice, so as to assess the wounds response to treatment. It is advisable that photographs of wounds take place using the cameras integral dating system, rather than dating the photograph by hand. Whilst most people who were prescribed thickening agent to enable them to swallow safely had care plans stating how thick their drinks needed to be, not all were, and it is advisable that this is consistently recorded, to fully inform staff. One persons food chart stated that they had been given a soft diet. However on discussion with the chef and carers, they reported that they ensured that choice was offered to people who needed a soft diet. So to assist staff in assessing that peoples dietary needs and preferences are met, the type of soft diet should be documented. During the inspection, we observed two medicines administration rounds. We observed that registered nurses performed medicines administration in a safe manner, carefully reviewing the medicines administration record before dispensing the drug. The registered nurses then consistently took the medicine to the resident and Care Homes for Older People Page 17 of 35 Evidence: observed them taking the medicine, before signing the medicines administration record. All medicines administration records were up-to-date. If a resident was unable to take a medicine or refused it, this was clearly documented. Where instructions relating to medicines needed to be altered, these were signed and counter checked. There were safe systems for storage of medicines, including Controlled Drugs. We did observe on one floor of the home that the Controlled Drugs cupboard was small and that if many more people were prescribed such drugs, a difficulty in being able to store such drugs could develop, so the home should consider purchasing a larger Controlled Drugs cupboard, before this happens. We observed that residents had care plans relating to their medicines, including as required medication. Care plans were clear and detailed why the person needed such medicines. Care plans were evaluated. It is advisable that evaluations be completed in more depth. For example one person was prescribed a Controlled Drug to ensure they were not in pain, with additional painkillers for any break-through pain, evaluations should consider how effective the additional painkillers were in supporting the resident with break-through pain. Another person was prescribed aperients which they were given as directed. The records showed that the person did receive such medication from time to time, so the medicines care plan would have benefited from crossreferencing to the persons bowel care plan, to assess the effectiveness of the intervention. We observed that all personal care was prescribed behind closed doors. Where residents shared a room, screening was used when indicated. In double rooms, we observed that all peoples personal effects, including toiletries and wash bowls were named and used only for them. All commodes were clean and any use of continence aids was discrete used. Small but significant details to a person were ensured when providing care. For example one frail person who spent most of their time in or by their bed had very attractively polished nails. Another residents care plan showed that they could become anxious at times and how staff were to reassure the person when this happened. Staff were observed to follow directions in care plans, so that the persons anxiety did not increase and the person be at risk of not having their privacy and dignity needs met. Care Homes for Older People Page 18 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home places an emphasis on residents having their social care needs met, being able to enjoy their meals and being able to exercise choice in their daily lives. Evidence: The Westbury employs a full-time activities coordinator. This person is prepared to work flexibly to meet the needs of residents. People commented to us in questionnaires about activities provision. One person reported I pick and chose the activity I join in with, another there is very good activities and another described the activities person as the best. During the inspection we discussed activities with people. They were able to show us the activities programme which they were given individually. One person described how they enjoyed the art classes, another person described the singsongs, with their eyes lighting up as they did so. During the inspection we observed an activities group and met with the activities coordinator. We observed in the main lounge that people were sitting in a group performing exercises to song. The activities person was encouraging residents to participate and the more able residents were supporting some of the less able residents. The activities person was very enthusiastic in their role. They showed a detailed individual knowledge of residents and their needs. They reported that they Care Homes for Older People Page 19 of 35 Evidence: went to see all residents every day. They were aware that many residents were not able, or did not wish, to come down to the sitting room, so they performed individual activities with such people. For example one person who did not leave their room, supported a particular football team, so the activities person reported that they always kept abreast of how their team was performing so that they could discuss this with them. For other people, they would visit them and discuss pictures of their families and others just have a cup of coffee and a chat. The activities person reported that they now felt supported by staff in their role and that if residents wanted to, staff ensured that they were able to come to the sitting room. They also reported that if they needed assistance now, if they rang for help, that staff came quickly. We reviewed their records and observed that they were clearly maintained, including the benefit to a resident of a particular activity. Residents records were person-centered, so that a clear profile of both their past lives and how they wished to spend their lives currently, were maintained. Records were completed in detail and were clearly up-dated when more information about a resident was identified. One residents care plan clearly documented a previous interest in gardening and how this could be considered when providing day-to-day care. Another person who spent most of their time in bed had details included in their care plan about how they liked to have their room laid out, so that they could see out of the door and talk to people when passing. The home were working with one resident to support them in going to a day centre, which they had attended prior to admission to the home. Non-nursing and care staff were also involved in supporting residents in their daily lives. A catering assistant was observed to use giving out morning coffee as an opportunity to chat with residents and engage them in conversation. This person reported that, due to this, giving out morning coffee could take some time, but that they felt that talking to residents was an important part of their role. The maintenance man reported that talking to residents was a part of the job that they really enjoyed and described how some residents enjoyed it when he needed to attend to something in their room. Records provided clear evidence of contacts with the residents families. People commented on the meals. One newly admitted resident reported theres nothing I dont like about the meals, another person who was on a specific diet reported that they treat me very well from the kitchen, little treats and so on and another person described meals as beautifully turned out. People commented on specific meals. One person described the beautiful fish pie and another the bread and butter pudding. People commented on the flexibility of the meals in the home. One person who said that they were a fussy eater reported that there were usually a could of times a week something I dont like and they always do me something else. Another person reported that they could have a hot meal in the evening if they Care Homes for Older People Page 20 of 35 Evidence: wanted. We met with the chef, who was very enthusiastic about their role. They reported that they had fully revised the menu since the last inspection and ensured that it incorporated principals of health eating. They reported that they met regularly with all residents in the home, so that they could keep abreast of their opinions on the meals. They showed a good knowledge of special diets. They had introduced choice for residents who needed a soft or liquidised diet. They had worked with the new manager to improve the atmosphere in there dining rooms and more people now came to the dining room for lunch and some people now came down for supper. We noted when reviewing residents weight records that many of the residents were slowly making improvements in their weight. This provides evidence that they are being supported by a catering service which is providing nutritious meals, that the resident wishes to eat. We observed a lunch-time meal and noted that there were more residents in the dining room than at the last inspection. Where people were not able to come to the dining room, the service had improved and meals no longer remained for extended periods in trolleys, becoming dry. Staff on the first floor were given extra sauces and gravies to use when needed. We observed that where residents needed assistance to eat, that staff sat with them, supporting them in conversation and ensuring that they were able to swallow safely. We observed in the dining room, that someone had requested a meal which was not on the menu for the day and that they had been given this. We observed a care assistant supporting a person in giving themselves their meal, making sure that they did not have too much food on their fork and put themselves at risk of choking. The atmosphere of the meal time was relaxed, with no sense of rush and staff were enabled to take their time, supporting residents. Care Homes for Older People Page 21 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will consistently have their complaints and concerns listened to and acted upon when indicated and be safeguarded. Evidence: At the last inspection, this area was judged to have poor outcomes for people. Since the inspection, the home has put significant efforts into improving this area. This was reflected in what people told us. All of the eleven people who responded to this section of the questionnaire reported that they knew how to make a complaint. One person reported our new manager will ALWAYS listen to any resident or relative at any time, another family always know who to speak to and another no complaints at this time thanks to [the manager]. During the inspection, we noted that the complaints procedure was readily available in the front entrance area and in the service users guide, a copy of which was available in each residents room. The prospective manager maintains very clear records of complaints received and also documents all concerns raised with them, including matters raised verbally. Records showed that the home were complying in full with their complaints procedure. All records showed outcomes of complaints and actions planed to taken to ensure any issues identified were acted upon. People we met with during the inspection echoed what was reported in the questionnaires. One person reported that if they were concerned about anything Care Homes for Older People Page 22 of 35 Evidence: would they ask carers and they find someone and they get someone to see me, another oh yes you can talk to her - about the prospective manager and another that the manager listens and she acts. A member of staff reported that the new manager had been very supportive of residents relatives too and that all their niggles have gone. Staff reported to us that they knew what to do when complaints or concerns were reported to them and were confident that the new manager would take action, including supporting them, when relevant. At the last inspection, we were concerned about staff training on safeguarding vulnerable people. This has been fully addressed by this inspection and records showed that all staff had been trained in abuse awareness, including whistle blowing. Staff we spoke to were aware of their responsibilities in this area. One person reported Id report anything I see, if they had concerns about how people were being treated. We described different scenarios to a range of people, including non nursing and care staff such as the maintenance man and they were all fully aware of their responsibilities for safeguarding vulnerable people. Residents also reflected this. One resident reported I feel safe here. Residents also commented on changes made by the manager to help them in feeling safe. One person commented we now have a ground floor nurses station back so a nurse can now be found more easily. It is also better for peace of mind to know the nurse is at hand. Both the new manager and their deputy have had experience of working with local safeguarding processes. At the time of the inspection, a matter had been raised which related largely to the period before the new manager come in post. The new manager has cooperated in full with the investigative process. The deputy manager reported that, to ensure that residents were safeguarded, and staff fully prepared they performed unannounced trial emergencies and that they had performed one the weekend before the inspection, This had showed a quick response by staff, to ensure that the scenario was dealt with promptly and efficiently. Care Homes for Older People Page 23 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will have their needs met in a pleasing, clean environment and equipment to meet their disability needs will be provided. Evidence: The Westbury was purpose-built as a care home a few years ago. Accommodation is provided over two floors, with a passenger lift in-between. All rooms are en-suite. Most accommodation is in single rooms, although some double rooms are provided. Where this is the case, suitable screening was available and used by staff. There is a large sitting room on the ground floor, which has access to the paved garden area. This area is wheelchair accessible. There is a separate dining room on the ground floor. A small sitting room is available on the first floor. The front entrance area has seating and this can be used by people if they wish. The home provides different assisted baths and showers, to suit people with a range of disability. At the last inspection, some issues were raised about equipment to meet the needs of residents with a disability. This has now been fully addressed. All residents who need specialist seating to meet their individual needs, now have it provided. There were a wide range of hoists to support residents with manual handling needs. Equipment to prevent pressure damage was available to all people who needed it. Profiling beds were provided, to reduce risks associated with the use of safety rails. We observed several occasions where residents were cared for in profiling beds which would go Care Homes for Older People Page 24 of 35 Evidence: down near to the floor, with crash mats being provided, if indicated. The maintenance man reported that staff promptly reported any issues which needed attention to him. They also reported that they were developing plans to improve the service corridor outside the kitchen and performing an analysis of sluice rooms so that they could assess how to make improvements to them, particularly to ensure that all surfaces are easy to keep clean. The maintenance man was aware that some rooms and areas needed re-decoration and was developing plans with the manager and other staff to identify how such matters could be addressed. For example they reported that they were aware that one resident only left their room once a fortnight, when they had their hair done. The maintenance man reported that they were planning round this with staff, so that they could get into the persons room at the time they were having their hair done so as to re-decorate areas which needed doing while the person was out. Once all such areas have been addressed, the home will be providing high standards of maintenance. Residents are enabled to bring in their own items if they wish. This gave some rooms a highly persona appearance, reflecting their likes and preferences. One resident commented to us its so lovely to be able to have my own furniture. Another resident had been supported in having their own desk and computer.Many residents had pictures of their families in their rooms. At the last inspection, issues were raised about cleanliness of the home. In their AQAA, the home reported on the steps taken to address this area. Unlike at the previous inspection, no-one raised issues with us about cleanliness and all parts of the home we visited were clean and smelt fresh. A hotel services manager has been appointed and this person reported that they had reviewed the cleaning systems, using different chemicals and investing in training for domestic staff. At this inspection, we did not observe any issues relating to commonly used items such as bath hoists and commode buckets. We did not visit the laundry, as at the previous inspection six months ago, the laundry was providing an effective service and fully complaint with the principals of prevention of spread of infection. Staff practice has improved since the last inspection and all topical creams were now labeled with the persons name and systems had been put in place, particularly in double rooms, to ensure that they were not used communally. We observed in some-ensuite rooms that a box of disposable gloves had been placed on the toilet cistern. Current good practice guidelines are that if disposable gloves are needed, they should not be placed on such as surface and a wall-mounted glove dispenser be provided. Care Homes for Older People Page 25 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents will be fully supported by staff who have been safely recruited and are fully trained so that they can meet residents needs. Evidence: At the last inspection, this area was assessed as having poor outcomes for people. Since the last inspection, the provider has made many improvements in this area, to ensure that outcomes for people are improved. In their AQAA, the home reported on the improved skill mix and the appointment of senior carers to provide support to both the registered nurses and junior carers. Of the eight staff who commented to us about staffing levels in questionnaires, three reported that there were always and five, usually enough staff to meet the needs of the residents. Residents commented to us about staffing levels during out inspection. One person reported that staff were very good at coming when they used their call bell, another I see plenty of people here about the staff, another I just ring my bell and they come, I have to have two, as I have to use a hoist and one person commented that staff were just as good at night at coming when they used their call bell. Staff we spoke with also reflected what residents reported and no-one reported, unlike at the previous inspection, that they felt they had to use a hoist on their own, due to not being able to find another member of staff able to assist them. Records showed that the home were no longer using agency staff. Care Homes for Older People Page 26 of 35 Evidence: The home have performed a full audit of staff files and ensured that all required information was in place. Considering the issues relating to this area identified at the last inspection, it is much to the providers credit that they have been able to make full improvements in this area. We reviewed the files of recently employed staff and noted that all staff had required police checks. All files showed proof of identity, two satisfactory references, a health status check and an interview assessment. Any gaps in employment history were probed. Where a member of staff started employment after they had been checked against the protection of vulnerable adults list but before their criminal records bureau clearance was obtained, there was clear evidence that the person worked fully supervised. The home have put much effort into improving their induction for new staff. We met with one person who had only recently commenced employment just before the previous inspection six months ago, and they reported that they had now received a full induction into their role. A person commented in their questionnaire lots of training now commenced but should have been done on induction. Another person commented I have recently started here and have found the atmosphere great and all staff work supportive. The provider has standard systems for induction of new staff, records seen showed that the home were keeping to this standard induction for new staff. At the previous inspection, it was identified that a requirement in the previous inspection relating to staff training had not been addressed. The provider has also put much work into this area. One person commented in their questionnaire training up to date now being given and another lots of training available plus distance learning. We discussed training with staff during the inspection and they were clear that they were now receiving training so that they could meet the needs of residents in the home. One member of staff reported that they had all the training that they needed. We looked at training records. The deputy manager reported that, as part of their role, they were responsible for facilitating training. This person saw their role in training as a key area and clearly enjoyed the role, particularly ensuring that needed developments take place. They maintained a matrix of training so that they could see at a glance which members of staff had particularly in training and when. Training records provided evidence that all mandatory training in areas such as manual handling and infection control was now up-to-date. This was further evidenced by reviewing practice by staff, particularly in infection control - see Environment above. As well as mandatory training, training has also been provided in areas such as pressure damage prevention, nutrition, complaints management and palliative care. The provider also runs its own internal programme, supporting staff in understanding the importance of person-centered care. Several people commented to us on recent Care Homes for Older People Page 27 of 35 Evidence: dementia care training. One person commented particularly on how the training had helped them to understand more about different forms of dementia and how it affected people. Records showed that the provider is supportive on National Vocational Qualifications for all relevant staff. Care Homes for Older People Page 28 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be fully supported by the management systems in the home, this will ensure their health, safety and welfare. Evidence: A new manager has been appointed to the home since the last inspection. This manager is an experienced manager, who has worked in other homes within the provider and has an established history of making improvements in homes where deficits in performance have been identified. A wide range of people commented on how effective the manager had been in improving service provision. One person commented the difference she has made to this home in the short time she has been here is phenomenal. She has made it a very happy home and another the home has benefited from a change in management, everyone seems much happier, especially the staff. Staff also commented on the new manager. One person reported since the appointment of our new manager we are able to prove what a good team we are with her encouragement we are now delivering the standards of care we used to and another our new manager has uplifted the home, people enjoy going to work. Many Care Homes for Older People Page 29 of 35 Evidence: people, both staff and residents commented to us during the inspection on the new manager effective open door policy and how accessible they were. One person described the new manager as very fine and another said what a difference the new manager had made to the home, particularly staff morale and the atmosphere. A member of staff described the new manager as brilliant and another reported everyone is now happy and how much they enjoyed coming to work. The new manager is supported by a newly appointed deputy, who has also worked elsewhere within the providers organisation. Several people commented on this person. One person reported that if they observed performance by another member of staff as not being what the resident needed, that they could report the matter to the deputy manager and that they would ensure that action was taken. Another person described them as very good at her job. We discussed with the new manager and their deputy if they would be remaining in their role, now that service provision had improved. The new manager reported that they were planning to stay in the home and that they were in the process of applying with us to be registered manager of the home. We discussed that as the manager and her deputy have been so successful in improving quality of service provision that we would reserve the right to re-inspect the home, if they did decide to leave their role. The provider has established systems for reviews of quality of care provision. As the home was assessed as having poor outcomes for residents at the last inspection, the provider had ensured a range of reviews of quality of service provision. Initially, the provider was up-dating us on a weekly basis, informing us of where they had taken action and action plans for further improvement. Once improvements were established, they contacted us fortnightly to inform us of progress. This shows that the provider is prepared to work closely with us and in a constructive manner. The new manager performs regular reviews of service provision, including incidences of pressure ulceration, infections and accidents. They had reviewed response times to call bells and taken action to identity deficits. They had made improvements to the emergency alarm system to ensure that people responded more effectively when the emergency bell was used. The new management team has set up a system for staff supervision, which the last inspection showed needed much attention. During the inspection we met with a senior carer who acted as supervise for a more junior carer. They both clearly had an effective working relationship. The more junior carer reported that they could go to their supervisor with queries when they needed and felt supported in their role. The senior carer also reported that they had also learnt from the junior carer. The deputy Care Homes for Older People Page 30 of 35 Evidence: manager reported that they had ensured that all staff had received an individual appraisal. Due to the amount of development needed, they had commenced with small group supervisions, on topic lead areas such as safe manual handling. At present few supervisions were on a one-to-one basis, following observations of practice. The deputy manager reported that now that a supervision system had been established, this was an area for future development. We met with the administrator, who had been newly appointed. They showed us the systems for management of residents day-to-day moneys. The provider has standard systems for management of residents moneys, with individual computerised accounts for each resident. There are clear systems for additional services such as hairdressing or chiropody. Accounts were clear and easy to audit. The home also has a clear system for moneys and valuables handed in for safekeeping, with a full audit trail. The provider has standard systems to ensure that equipment and services are regularly maintained. The handyman had full records relating to this, which shows that they are keeping to the providers systems. The fire log book and risk assessment were now fully up-to-date. This home had a recent small fire, which they reported to us. Evidence from the home and other sources showed that staff performed as expected and no issues of concern were identified. No residents were placed at risk by the fire. Generic risk assessments for the home have been fully reviewed by the new manager Care Homes for Older People Page 31 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 7 7 Photographs of wounds should include the date of the photograph, using the cameras intergral dating system. Where a person is prescribed thickening agent to enable the person to swallow safely, all care plans should state how thick their drinks need to be. Records of food given to residents should state what they were given rather than soft diet. Where a person is receiving oxygen, their care plan should state how often the tubing needs to be changed and any other intervention relating to cleanliness of the tubing. A larger Controlled Drugs should be provided in the first floor clinical room. Evaluations of care plans relating to residents medication should include a more detailed assessment of the benefit (or otherwise) of the drug for the resident. If disposable gloves are needed for personal care, in sanitary facillities, they should be placed in wall-mounted glove dispensers, not on a flat surface. 3 4 7 7 5 6 9 9 7 26 Care Homes for Older People Page 33 of 35 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 8 36 Systems for more one to one supervisions, based on working with people and observing practice, should be developed. Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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