Care Home: Westhaven Nursing Home

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What the care home does well Service users’ care needs are assessed before they move into the home to ensure the staff have the information they need on how to provide the right level of care. Three of the health care professional surveys returned to us indicated the home’s assessment arrangements ‘always’ ensure that accurate information is gathered and that the right service is planned for. Three surveys indicated this was ‘usually’ the case. Service users’ general welfare is monitored daily and staff seek advice from different health care professionals as required. The service users spoken to during the visit confirmed their care needs are fully met and they are happy with the care and support they receive. One of the staff surveys returned to us noted ‘Westhaven has a warm, pleasant atmosphere. The residents are well cared for with their individual needs being met’. Three of the health care professional surveys returned to us indicated service users’ social and health care needs are ‘always’ properly monitored, reviewed and met by the staff. One of the service user’s relatives said ‘The staff are excellent. They always keep me informed about my relative’s welfare’. Systems are in place for the administration of service users’ medication. Staff who administer medication are trained in this area of care so they are aware of their responsibilities and know how to work safely.Westhaven Nursing HomeDS0000020915.V376318.R01.S.docVersion 5.2The service users spoken to during the visit said the staff are very good when they help them with their personal care. One service user said ‘The staff are always very good when they help me get washed and dressed’. Another service user said ‘The staff are very kind and caring, nothing is ever any trouble to them’. An activity organiser is employed at the home and a range of group and individual activities are provided. This gives service users an opportunity to meet the other people living in the home and prevents them from getting bored. A number of volunteers visit the home regularly to support the social activities. The service users spoken to said they enjoy the food and always have plenty to eat. One of the service users said ‘The food is excellent and always well cooked’. The menu is varied and changed regularly. The mealtimes are relaxed and informal. A complaint procedure is available to service users and their relatives so they know what to do if they are unhappy with the care they receive. We have not received any complaints about the standard of the service provided at Westhaven. Staff have completed training on how to safeguard service users from abuse. No allegations of abuse have been made at the home. The service users said the staff are very kind and caring. One service user said ‘The staff are marvellous’. Another service user said ‘The staff are always very kind and I have never been spoken to or treated badly’. The home is well maintained and provides a comfortable, homely and safe environment for service users to live. The premises are secure, bright and airy. Specialist equipment such as a lift, assisted bath, hoists and toilet aids are provided to support service users with their independence and to minimise the risk of accidents happening. Staff are provided with regular ongoing training to support them in their role and keep them up to date with new ways of working. The manager, Mrs Margaret Stewart, is qualified, competent and experienced to run the home. The staff spoken to during the visit said the manager is always available for support and advice. One of the health care professional surveys returned to us noted ‘The matron and senior staff are excellent nurses to work with and make my job easier’. Quality assurance systems are in place to ensure the ongoing efficient and effective running of the service. What has improved since the last inspection? Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Since the last inspection staff have been provided with training on the use of bed rails, how to safeguard service users from abuse, dementia care and leadership. A menu board is now clearly displayed and the back garden is now secure. What the care home could do better: More detailed information needs to be included in the care plans to ensure staff can accurately monitor and review service users’ well being and ensure all aspects of their care needs are planned for and met. More detailed information needs to be recorded in the risk assessments to ensure staff have all the information they need on how to minimise the risk of accidents happening. Service users cannot eat together as there are insufficient dining room tables and some have to eat in the lounge area using smaller side tables. This situation is not ideal and the provider should review this to ensure service users can eat at the dining room table. The nurse call alarm system is very highly pitched. For staffs benefit, it is recommended that the noise level is lowered. More nursing staff should be on duty each morning to ensure service users’ care needs are continually met. Key inspection report CARE HOMES FOR OLDER PEOPLE Westhaven Nursing Home 11-15 Queens Road Hoylake Wirral CH47 2AG Lead Inspector Inger Moynihan Key Unannounced Inspection 22 September 2009 09:30 DS0000020915.V376318.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westhaven Nursing Home Address 11-15 Queens Road Hoylake Wirral CH47 2AG 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) 0151 632 1737 0151 632 3758 Dove Care Homes Ltd Margaret Lawrie Stewart Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 34 Date of last inspection 12th November 2007 Brief Description of the Service: Westhaven is three Victorian terraced houses converted to use as a nursing and personal care home. The home is over two floors, and has a passenger lift. The majority of the rooms are large, single rooms, but none are en-suite. However, all are very nicely furnished according to the individual residents preferences, and have hand-wash basins. There are garden spaces to the rear of the home and spaces for car parking. The home is set in a quiet road close to Hoylake main street, and is easily accessible to local amenities and transport links. Fees range from local social services funded to privately agreed rates for individual service users. Westhaven Nursing Home DS0000020915.V376318.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. Information about the home was obtained through discussion with the manager and members of the staff team. Policies, procedures and supporting documentation were also looked at along with a selection of service users case files. We also obtained information from the Annual Quality Assurance Assessment (AQAA). The AQAA is a self assessment document that is filled in once a year by all providers. It is one of the ways that we get information from providers about how they are meeting outcomes for people using the service. A part of the inspection process includes sending surveys to service users, staff and health care professionals in order to obtain their views on the standard of the service provided. Six staff surveys and six health care professional surveys were returned to us. Comments made in these surveys are included in the report and contribute to the basis of any judgments made. What the service does well: Service users’ care needs are assessed before they move into the home to ensure the staff have the information they need on how to provide the right level of care. Three of the health care professional surveys returned to us indicated the home’s assessment arrangements ‘always’ ensure that accurate information is gathered and that the right service is planned for. Three surveys indicated this was ‘usually’ the case. Service users’ general welfare is monitored daily and staff seek advice from different health care professionals as required. The service users spoken to during the visit confirmed their care needs are fully met and they are happy with the care and support they receive. One of the staff surveys returned to us noted ‘Westhaven has a warm, pleasant atmosphere. The residents are well cared for with their individual needs being met’. Three of the health care professional surveys returned to us indicated service users’ social and health care needs are ‘always’ properly monitored, reviewed and met by the staff. One of the service user’s relatives said ‘The staff are excellent. They always keep me informed about my relative’s welfare’. Systems are in place for the administration of service users’ medication. Staff who administer medication are trained in this area of care so they are aware of their responsibilities and know how to work safely. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 6 The service users spoken to during the visit said the staff are very good when they help them with their personal care. One service user said ‘The staff are always very good when they help me get washed and dressed’. Another service user said ‘The staff are very kind and caring, nothing is ever any trouble to them’. An activity organiser is employed at the home and a range of group and individual activities are provided. This gives service users an opportunity to meet the other people living in the home and prevents them from getting bored. A number of volunteers visit the home regularly to support the social activities. The service users spoken to said they enjoy the food and always have plenty to eat. One of the service users said ‘The food is excellent and always well cooked’. The menu is varied and changed regularly. The mealtimes are relaxed and informal. A complaint procedure is available to service users and their relatives so they know what to do if they are unhappy with the care they receive. We have not received any complaints about the standard of the service provided at Westhaven. Staff have completed training on how to safeguard service users from abuse. No allegations of abuse have been made at the home. The service users said the staff are very kind and caring. One service user said ‘The staff are marvellous’. Another service user said ‘The staff are always very kind and I have never been spoken to or treated badly’. The home is well maintained and provides a comfortable, homely and safe environment for service users to live. The premises are secure, bright and airy. Specialist equipment such as a lift, assisted bath, hoists and toilet aids are provided to support service users with their independence and to minimise the risk of accidents happening. Staff are provided with regular ongoing training to support them in their role and keep them up to date with new ways of working. The manager, Mrs Margaret Stewart, is qualified, competent and experienced to run the home. The staff spoken to during the visit said the manager is always available for support and advice. One of the health care professional surveys returned to us noted ‘The matron and senior staff are excellent nurses to work with and make my job easier’. Quality assurance systems are in place to ensure the ongoing efficient and effective running of the service. What has improved since the last inspection? Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 7 Since the last inspection staff have been provided with training on the use of bed rails, how to safeguard service users from abuse, dementia care and leadership. A menu board is now clearly displayed and the back garden is now secure. What they could do better: 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 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. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 8 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 Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users care needs are assessed before a service is offered so they know they will receive the care and support they need. EVIDENCE: Service users’ care needs are assessed before they move into the home. The service user, their family and any relevant health care professional can contribute to the assessment to ensure the staff have all the information they need on how to provide the right level of care. Issues relating to equality and diversity such as service users disability, gender, age and religion are addressed to ensure their holistic care needs are met. Three staff surveys returned to us indicated they are ‘always’ given up to date information about the needs of the people they support and care for. Three surveys indicated this was ‘usually’ the case. Three of the health care professional surveys returned Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 10 to us indicated the home’s assessment arrangements ‘always’ ensure that accurate information is gathered and that the right service is planned for. Three surveys indicated this was ‘usually’ the case. Intermediate care is not provided at Westhaven care home. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users’ personal care needs are met and they are treated with respect and valued as individuals. EVIDENCE: A plan of the care provided to each service user is in place. Service users’ general welfare is monitored daily and staff seek advice from different health care professionals as required. The service users spoken to during the visit confirmed their care needs are fully met and they are happy with the care and support they receive. The manager agreed that more detailed information needs to be included in the care plans to ensure staff can accurately monitor and review service users’ well being and ensure all aspects of their care needs are planned for and met. A range of risk assessments had also been completed as part of the care plan. Again the manager agreed more detailed information needs to be recorded to ensure staff have all the information they need on how to minimise the risk of accidents happening. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 12 One of the staff surveys returned to us noted ‘Westhaven has a warm, pleasant atmosphere. The residents are well cared for with their individual needs being met’. Three of the health care professional surveys returned to us indicated service users’ social and health care needs are ‘always’ properly monitored, reviewed and met by the staff. Three surveys indicated this was ‘usually’ the case. A number of relatives were spoken to during the visit. They said they are very happy with the way the way their relatives are being cared for. One relative said ‘The staff are excellent. They always keep me informed about my relative’s welfare’. Another relative said ‘I am very happy with the care my mum receives. The staff are always professional and polite’. Systems are in place for the administration of service users’ medication. Appropriate facilities are provided for the safe storage of medication and supporting policies and procedures are available to staff if they need clarification on a specific issue. The medication administration record sheets were accurately maintained. Staff who administer medication are trained in this area of care so they are aware of their responsibilities and know how to work safely. Service users spoken to during the visit said they always receive their medication on time. The staff ensure service users are treated with respect and their right to privacy is upheld. The service users spoken to during the visit said the staff are very good when they help them with their personal care. One service user said ‘The staff are always very good when they help me get washed and dressed’. Another service user said ‘The staff are very kind and caring, nothing is ever any trouble to them’. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 People using the 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’s routines are flexible and service users are helped to exercise choice and control in their lives. EVIDENCE: An activity organiser is employed at the home and a range of group and individual activities are provided. This gives service users an opportunity to meet the other people living in the home and prevents them from getting bored. A programme of activities is in place and includes outside entertainers and trips out to the local shops and promenade. The activity co coordinator will read to service users who have sight problems and the community library visits the home regularly. A number of volunteers visit the home regularly to support social activities. Service users’ social care needs are assessed when they first move into the home, this information forms part of their care plan. As indicated earlier in the report, more detailed information must be recorded in the care plans to ensure they accurately reflect service users’ individual social care needs. Service users said they enjoy the activities provided and staff respect their choice not to join in. The manager is planning to hold service Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 14 user meetings so they can be involved in the development of the activity programme. Family/service user social events are also held to keep people informed about the development of the service and to bring a sense of community to the home. Service users’ friends and family can visit at any time so they can maintain personal relationships and continue to be part of family life. The service users said the home’s routines are flexible which means they can make decisions for themselves and go about their day as they wish. The service users spoken to said they enjoy the food and always have plenty to eat. One of the service users said ‘The food is excellent and always well cooked’. Another service user said ‘The food is very good and sometimes there is too much. There is always a choice and the staff get to know what you like and dont like’. Diets based around service users’ medical and cultural needs can be met and hot and cold drinks are available throughout the day. Staff are available to help service users at mealtimes if necessary. The menu is varied and changed regularly. The mealtimes are relaxed and informal. Service users cannot eat together as there are insufficient dining tables and some have to eat in the lounge area using smaller side tables. This situation is not ideal and the registered provider should review this to ensure service users can eat at the dining room table. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to ensure service users are protected from abuse. EVIDENCE: A complaint procedure is available to service users and their relatives so they know what to do if they are unhappy with the standard of care they receive. Service users spoken to said they are aware of the home’s complaint procedure. We have not received any complaints about the standard of the service provided at this care home. The manager has received one complaint in the last year. This complaint has been investigated and concluded and was partly upheld. Staff have completed training on how to safeguard service users from abuse. During discussion they gave a basic understanding of the different types of abuse can occur and what they should do if they know or suspect abuse is happening. A copy of the necessary adult protection procedures are in place which means allegations of abuse are managed correctly. A whistle blowing procedure is in place so that staff can raise concerns anonymously. Some of the staff were not clear on the meaning of whistle blowing. The manager should update staff on to this area of care so they know how to raise an anonymous concern. No allegations of abuse have been made at the home. The service users said the staff are very kind and caring. One service user said Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 16 ‘The staff are marvellous’. Another service user said ‘The staff are always very kind and I have never been spoken to or treated badly’. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The building is well maintained and provides a comfortable and homely environment for service users to live. EVIDENCE: The home is well maintained and provides a comfortable, homely and safe environment for service users to live. The premises are secure, bright and airy. There is a programme of routine maintenance to ensure the home is maintained to a good standard. There is a large garden at the back of the home which service users can use when the weather is good. This area would benefit from some improvement to make it more attractive for service users and their visitors. The staff smoking area should be moved out of sight. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 18 The bedrooms are spacious and bright and service users have personalised their rooms with their own belongings. Specialist equipment such as a lift, assisted baths, hoists and toilet aids are provided to support service users with their independence and to minimise the risk of accidents happening. Systems are in place to prevent the spread of infection and there are sufficient laundry facilities for the number of people living at the home. Infection control policies and procedures are available to staff so they know how to work safely. The deputy manager is the designated infection control coordinator. This means staff keep up to date with current good practice and changes to legislation. The nurse call alarm system is very highly pitched. For staff benefit, it is recommended that the noise level is lowered. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by suitably qualified and competent staff. EVIDENCE: The manager and deputy manager reported there are insufficient nursing staff on duty each morning and the home would benefit from an increase in staffing hours. She reported that there is not enough work for two trained nurses all of the time but too much work for one nurse particularly in the morning. In recognition of this the manager provides additional support to ensure clinical needs are met. This was also noted in five of the six surveys which indicated there are ‘usually’ enough staff to meet the individual needs of the people who use the service. One of the staff surveys noted when asked what could the home to better? ‘Extra staff would be nice’. One of the health care professional surveys returned to us noted when asked the same question, ‘More staff leading to better care’. This issue should be addressed to ensure service users’ ongoing care needs are continually met. Criminal Record Bureau (CRB) checks are completed before staff begin working at the home. It is recommended these checks are completed every three years. A policy should also be drawn up which asks staff to declare any offences after the CRB check has been completed. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 20 There is training to the National Vocational Qualification standards which is a recognised qualification for staff involved in the care profession. Staff are provided with regular ongoing training to support them in their role and keep them up to date with new ways of working. A training plan is not in place for next year. The manager should carry out a training need analysis with each member of staff, the outcome of which should formulate the basis of next years training programme. This will ensure the training is focussed on staff training requirements and service users’ specific care needs. Newly appointed staff receive induction training which means they are clear on their responsibilities and know what is expected of them. Four staff surveys returned to us indicated the training covered everything they needed to know to do their job when they started. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management systems ensure the home is run efficiently and for service users best interest. EVIDENCE: The manager, Mrs Margaret Stewart, is qualified, competent and experienced to run the home. The management structure reflects the size of the home and there are clear lines of accountability within the staff structure. The staff spoken to during the visit said the manager is always available for support and advice. One of the health care professional surveys returned to us noted ‘The matron and senior staff are excellent nurses to work with and make my job easier’. One of the relatives spoken to said ‘The home is managed very Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 22 efficiently and issues are dealt with promptly’. The manager reported she has a good relationship with her line manager and feels well supported in her role. It is recommended that the manager has regular formal supervision so she has an opportunity to discuss her personal development and how she intends to develop the service. Quality assurance systems are in place to ensure the ongoing efficient and effective running of the service. This includes monitoring and supporting staff, reviewing administrative systems and consulting with service users and their relatives about the care provided. The manager communicates a clear sense of direction and leadership so that staff are aware of their responsibilities and know how to maintain good standards of care. One of the staff surveys returned to us noted ‘The home has a very good reputation with vacancies few and far between. One can only surmise therefore that the home does everything well’. One of the health care professional surveys returned to us noted ‘I find the matron, Margaret Stewart, committed and active on her residents’ needs’. The manager assured us that the issues raised in this report will be addressed as a matter of priority. Staff do not take responsibility for managing service users’ finances. Staff spoken to during the visit said they enjoy their work and feel well supported in their role. They confirmed a senior member of staff is always available for advice and support. A system of formal supervision is in place which gives staff an opportunity to meet with their line manager and discuss their development within their role. All staff have an annual appraisal of their work. One of the staff surveys returned to us noted ‘I have been happy working at Westhaven and have a good relationship with my colleagues, the matron and all the staff’. Another surveys noted ‘The staff work well as a team and are very caring’. The health, safety and welfare of service users and staff are promoted through the provision of staff training, supporting policies and procedures and regular health and safety checks around the building. Small electrical appliances are tested by the maintenance staff. This member of staff should be trained in this area. Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 23 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 2 8 X 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP7 Good Practice Recommendations More detailed information should be recorded in the care plan and risk assessment documentation. This will ensure staff have the information they need to how to look after the service users in accordance with their individual care needs and minimise the risk of accidents happening. The current arrangements in place for dining should be reviewed so that service users have an opportunity to eat at a dining table. The tone of the nurse call bell system should be lowered to provide staff with a better working environment. The garden should be improved to make it more attractive to service users and their visitors. The staff smoking area should be moved out of sight. 2. OP15 3. 4. OP19 OP19 Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 25 5. 6. OP27 OP29 More nursing staff should be provided each morning to ensure service users’ care needs are continually met. A CRB check should be completed on each member of staff every 3 years. This will ensure they are suitable to work with older people. A policy should be implemented which asks staff to declare any offences after their CRB check has been completed. This will ensure they are suitable to work with older people. A training plan for the forthcoming year should be established. This will ensure the training is focussed on staff training requirements and service users’ specific care needs. The manager should be provided with formal supervision and an annual appraisal of her work. This will provide her with an opportunity to discuss her personal development and how she plans to develop the service. 7. OP29 8. OP30 9 OP31 Westhaven Nursing Home DS0000020915.V376318.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. 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