Care Home: Westerley

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What the care home does well What has improved since the last inspection? The following improvements have been made: Accredited medication, infection control, health and safety and first aid training. New policies and procedures. Using residents` input more into daily menus, life and activity programme. A 3-star hygiene award by local environmental health officer. Training in the protection of vulnerable adults. Central heating system upgraded/replaced Kitchen refurbished, including new oven and dishwasher New fire alarm panel installed and new alarm sounders in all rooms. An improved knowledge of working practice and new legislation through head office management meetings. What the care home could do better: Pureed meals provided to residents unable to eat solids would be more enjoyable and taste better if meat, vegetables, potatoes etc. were pureed separately. One of the bathrooms and a shower room would benefit from some pictures, curtains, plants etc. to give a more homely feel. CARE HOMES FOR OLDER PEOPLE Westerley Broadway Woodhall Spa Lincs LN10 6SQ Lead Inspector Julie Western Unannounced Inspection 12th August 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westerley Address Broadway Woodhall Spa Lincs LN10 6SQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01526 352231 woodhall@lpma.co.uk The Leaders of Worship and Preachers Homes Jayne Margaret Tewnion Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Westerley is registered to provide personal care to male and female service users who fall within the following categories: Old age, not falling within any other category. The maximum number of persons to be accommodated at Westerley is 26. 17th August 2006 Date of last inspection Brief Description of the Service: Westerley is situated in the spa town of Woodhall Spa and in close proximity to local shops, churches, chapels, park, kinema and other community amenities. The building is a Victorian former private house and stands in its own grounds in a residential area opposite the Golf Hotel and golf course. There are gardens to three sides and parking for several cars to the front. It is registered to give care and accommodation for up to 26 residents and all of the bedrooms have en-suite facilities. There is a lift to the first floor. The home is run by the Leaders of Worship and Preachers homes trading as LWP Homes and there are currently four care homes throughout the country. The organisation is a Christian charity set up specifically for Methodist Local Preachers and their dependents. However, their homes now accept applications from Lay Preachers and service users from other denominations. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was carried out over three hours and took into account any previous information held by CSCI including the home’s previous inspection reports, its service history, any pre-inspection questionnaires completed by the Manager including the Annual quality assurance assessment [AQAA] and any residents’ questionnaires sent to the home by the Commission prior to the inspection. The site inspection was unannounced and consisted of tracking a sample of residents’ care records and assessing the care given. Some policies and procedures were examined and some records concerning the safety of the home were also seen. Four residents and two care and ancillary staff were spoken with. The Manager and the deputy manager were both present throughout the inspection. What the service does well: The home provides a comfortable, safe and homely environment for people to live in. It is very well managed and organised. Residents have detailed care plans and reviews are carried out frequently; families and other professionals are involved in the reviews. There is a wide range of activities for residents to choose from and meals are varied and balanced; one resident said ‘It’s wonderful here – like being on holiday’ and comments from survey forms returned included ‘‘It is not just inside but the garden and the hanging baskets are kept beautiful’ and ‘In general the care we receive is good and the care staff are very kind and thoughtful and help as much as they can and when help is needed’. Staff members are well trained and have a sound knowledge of residents’ needs. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westerley DS0000002473.V370103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The information provided is freely available to residents. A comprehensive initial assessment ensures that the needs of residents can be met. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: The manager confirmed that she or, in her absence, the deputy or assistant manager, always visited prospective residents at home or in a care setting such as a hospital to undertake a thorough assessment of all their care needs. Records confirmed this. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 9 Written admission documentation was comprehensive and clear, giving staff the information they needed to meet the residents’ needs. All documents such as issuing contracts are managed by the head office. The statement of purpose and service user guide contained all of the information needed and there was also a brochure, which the manager said was given to all prospective residents on application. A resident described how she had visited several times and stayed for coffee and meals before she was sure he wanted to move in permanently. A staff member described the admission process and the importance of making new residents Westerley DS0000002473.V370103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in sufficient depth and detail to ensure that residents’ care needs can be met. EVIDENCE: The care plans looked at in depth, contained information about the residents’ health and personal care needs. They were reviewed regularly and signed where possible by the service user or relatives/advocates. They contained clear risk assessments. Social histories ensured that there was plenty of information to meet residents’ social needs. There was a clear medication policy and the pharmacist visited quarterly, the most recent visit from the pharmacist being 09/07/08 and the comments were ‘everything is in order’. The pharmacist also carries out training when asked. The monitored dosage system was used and all drugs were kept in a locked cupboard. The manager is a trained nurse. Two residents administered their Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 11 own medication and the relevant documents were in place to ensure this happened safely. Residents received regular visits from district nurses and other agencies involved with their care. Residents spoken with said that they were happy with the way they were looked after; one described how her medication was given to her and said ‘They look after my pills for me’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are regular and are tailored to suit individual residents’ needs. Residents have a choice of meals from a balanced and varied menu. EVIDENCE: Residents spoken with said they were very satisfied with the lifestyle at the home. One said ‘I can choose what I want to do and they always help me if I need to go shopping’. The service actively promotes independence, choice and privacy by listening to residents and relatives/representatives. Equality and diversity are promoted through the policies and procedures and through the staff induction procedures, ensuring that residents’ individual needs can be met. Although the home is mainly for Methodists, other denominations and non-practising Christians are now admitted and the manager said this has led to a more diverse group of people. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 13 The notice board displayed forthcoming activities. The programme of regular activities includes entertainers, armchair exercises, ‘knit and natter’ groups, music for health, ‘sing-alongs’, scrabble, dominoes, slide shows, outings to local tearooms, the Kinema and shopping. Residents can attend any of the local church services and devotions are held each morning. On the day of the inspection most residents were seen to be quietly resting in all of the three lounges. There is an open weekend held annually, to which local residents are invited and they are also invited to coffee mornings. Details of forthcoming events were displayed in the entrance area and residents spoken with all said they had a choice of whether or not to take part. Residents were observed eating the mid-day meal. All residents said they enjoyed the meals served; one said ‘It’s excellent food, you couldn’t want better’. The day’s menu was displayed in the corridor near the kitchen and offered alternative choices of meals. The eight-week rota showed balanced and varied meals and there was a use of fresh local meat and vegetables. The cook said that she visited each resident daily with the choices for the day and if residents didn’t like any of the choices, she would make them an alternative. Three residents were being given pureed food and this was served as one liquidised meal. It was suggested that the individual meat, potatoes and vegetables be pureed separately to allow the residents more taste experience. The Environmental Health Officer had visited the kitchens and awarded 3 stars for hygiene in the local award scheme. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s procedures for addressing complaints and for protection from abuse are clear. Residents and their families are confident that their comments and concerns will be listened to. EVIDENCE: Residents spoken with said they did not wish to complain but knew how to make a complaint. The home had an up to date copy of the Local Authority adult protection procedures; staff members said they had read it. The manager said that residents and their families were regularly asked for their views regarding the running of the home. Since the last inspection there had been no complaints. Staff spoken with confirmed that they had received training in safeguarding adults and the manager said that the most recent safeguarding training included a DVD from the Mulberry Trust, together with a workbook that staff members had to complete. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a safe, comfortable and pleasant environment that is suitable for their needs. EVIDENCE: Overall, the standard of decoration internally was high and afforded residents a great degree of comfort. There was a choice of three lounges for residents to choose from, giving plenty of communal space. Residents’ rooms were well personalised and decorated. A bathroom and shower room, while clean, were bare and not particularly homely. The gardens were very well maintained and offered pleasant places for residents to sit out in good weather, including a summerhouse. It was Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 16 suggested that the raised beds surrounding the walkways were planted with sensory plants for people with poor eyesight to enjoy. Staff members described how the maintenance worker carried out any repairs needing attention. The manager described the process for funding repairs/refurbishment and staff confirmed that these were always carried out swiftly. Recent improvements had included the central heating system being upgraded/replaced and the kitchen refurbished, including a new oven and dishwasher. A new fire alarm panel had been installed with new alarm sounders in all rooms. There were safety notices around the building to prevent the spread of infection and COSHH regulations were observed throughout. A risk assessment of the building had recently been carried out. The building smelled clean and fresh throughout. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent to meet the needs of residents. EVIDENCE: The daily staff rota showed that there were usually one senior plus three care staff for 25 residents. In addition the manager was present Monday to Friday. Both staff members and residents said they thought there were enough staff to meet their needs. The home also employed 2 domestic staff, a laundry person, a cook, a handyman and a gardener. The manager said that all staff member except two either have the National Vocational Qualification [a nationally recognised qualification] at Level 2 or 3. The core staff group is very stable, one staff member having worked at the home for over 20 years, which is longer than any of the current residents. A staff member described how she had an interview, gave three references and underwent an induction and CRB/POVA checks. Staff records confirmed this. Staff training records demonstrated that statutory training has been undertaken, with one of the most recent additional training sessions being on Alzheimer’s awareness and the Mental Capacity Act. The training given used a Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 18 mixture of in-house and external trainers. Staff members confirmed that they received regular supervision including appraisals. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, safety and welfare of the residents are promoted. The views of the residents are listened to and they are involved in decisions affecting them. EVIDENCE: The manager has been in post for two years. She has been and still is a registered nurse for over 30 years, 7 of these in a managerial position. She has the Registered Manager’s Award, as does the deputy manager. The residents have opportunities to air their views and said that the management team is very approachable. The home’s internal inspector visits Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 20 the home on a monthly basis and asks residents for their views on the running of the home. She also audits all other aspects of management of the home including monies such as petty cash and the audit is then sent to head office. The chairman of the trustees’ report was available to residents on the notice board. There are regular visits from one of the executives, who also line manages the manager. In addition, the managers from the trust’s four homes meet quarterly to discuss joint issues and visit each other’s homes. All the survey forms sent to the residents were returned and were positive, including comments such as ‘In general the care we receive is good and the care staff are very kind and thoughtful and help as much as they can and when help is needed’ and ‘It is not just inside but the garden and the hanging baskets are kept beautiful’. Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations 2. OP19 Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westerley DS0000002473.V370103.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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