Care Home: Westholme

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What the care home does well The home is well managed, staff work hard to maintain people`s choice and respect. People are encouraged to exercise choice about how and where to spend their time. There are opportunities to take part in social activities. People were very positive about living in the home. People told us "the staff are great, I enjoy everyday with them." "I am well looked after." "My mother is very happy to be at Westholme. She enjoys the meal provided and personal care is well taken care of. The staff are very approachable and always have time to discuss any relevant matters." "I choose how to spend my time." Staff said, "What we do well is to enable and encourage people`s independence." What has improved since the last inspection? Falls risk assessments are now completed for all people identified as been at risk, so that risks identified have an appropriate preventative action that must be taken to manage the risk. Care plans have improved to make sure people have a detailed care plan that gives staff clear instructions on how to deliver people`s care. Water-soluble bags are now used when laundering soiled linen. This will reduce the risk of cross infection in the home. CARE HOMES FOR OLDER PEOPLE Westholme Thornhill Road Upper Wortley Leeds LS12 4LL Lead Inspector Valerie Francis Key Unannounced Inspection 12th August 2008 10:00 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 Westholme DS0000033302.V370692.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. Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westholme Address Thornhill Road Upper Wortley Leeds LS12 4LL 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) 0113 2638203 0113 2638203 Leeds City Council Department of Social Services Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40) of places Westholme DS0000033302.V370692.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 only - Code PC, 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 and Physical disability - Code PD The maximum number of service users who can be accommodated is: 40 21st August 2007 2. Date of last inspection Brief Description of the Service: Westholme is a local authority home providing personal care without nursing for up to 40 older people. The home is situated in Wortley a suburb of Leeds and is near local facilities such as shops, pubs and a small park. Public transport is nearby and Armley Town Street is within 10 minutes walking distance of the home. Accommodation is provided in single rooms over two floors, with a passenger lift proving access to the second floor. There are small communal areas on both floors, the main dining room is on the ground floor, but a small additional dining room is available on the first floor. One of the lounges on the ground floor is designated as a smoking area. There are attractive gardens surrounding the home and there is a small car park at the front. The current scales of charges at the home range from £11. 02 per night to £497. 30 per week, this information was given to us at the time of this visit. More up to date information about fees can be obtained from the home. Not included in the fees are hairdressing prices which range from £5.00 to £18.00 and chiropody £17:00. People provide their own toiletries. Copies of previous inspection reports are available in the home. Westholme DS0000033302.V370692.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 stars. This means the people who use this service experience good quality outcomes. We did this unannounced visit in one day; one inspector visited the home between 10:00 am and 6:45 pm. The manager was not on duty at the time of the visit, the care officers facilitated in the process. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records and looked at parts of the building. The purpose of this inspection was to look at how the needs of people living in the home are being met. Before the visit we looked at the information we had received about the home since the last key inspection in August 2007. We also sent surveys to people living in the home, and staff and gave surveys to relatives that were visiting during the inspection. We sent a self-assessment form the AQAA (Annual Quality Assurance Assessment) to the home and it was returned to us in good time. It was clear and contained all the information we asked for. Feedback of our findings was given to the care officers on duty and the Principal Unit Manager who came at the end of the inspection. What the service does well: The home is well managed, staff work hard to maintain people’s choice and respect. People are encouraged to exercise choice about how and where to spend their time. There are opportunities to take part in social activities. People were very positive about living in the home. People told us “the staff are great, I enjoy everyday with them.” “I am well looked after.” “My mother is very happy to be at Westholme. She enjoys the meal provided and personal care is well taken care of. The staff are very approachable and always have time to discuss any relevant matters.” “I choose how to spend my time.” Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 6 Staff said, “What we do well is to enable and encourage people’s independence.” 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. Westholme DS0000033302.V370692.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 Westholme DS0000033302.V370692.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): 1, 3 & 5. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given the information they need to help them decide if the home is the right one for them and their needs are assessed before they move in. EVIDENCE: There is a wide range of information available in the front entrance of the home, so that people who currently live at the home, as well as those who are thinking about moving in, are aware of what the home has to offer. This is also available in an information pack in all bedrooms. People told us that they were given enough information about the home and the services provided before they decided it would be right for them. One person told us that they had “read an inspection report about the home before we visited.” Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 9 People and/or their relatives are encouraged to visit before making a decision about moving in. One person told us ‘‘my relative came and looked around and was given enough information about the home.” Staff said that most of the time, they will get information about new people before they move in from the social worker care needs assessment. This helps them to have an idea of what the person’s care needs will be when they are admitted. Westholme DS0000033302.V370692.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s care needs are met in a way that takes account of their preferences and abilities and respects their privacy and dignity. EVIDENCE: We were told that care plans are in place, which provide staff with detailed information about people’s personal, health and social care needs. Staff told us that there are regular care planning meetings that people living in the home and their relatives are involved with; this includes contact with the social worker and community nursing services. This makes sure that staff have the information they need to support people. The manager and care officer check the plans regularly to make sure they are kept up date. Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 11 We looked at three care plans. Two of the plans were detailed and up to date but one was not. Information given to us by staff about this person’s changed care needs were not reflected in the plan. For example they were receiving additional support from a health care professional and now needed support from staff with personal care. We were told that this would be dealt with straight away. We were shown a sample of new care plans, which the Principal Unit Manager said would give staff more information on how to deliver people’s individual care. We were told that nutritional risk assessments are only done if someone was at risk. One person had a nutritional risk assessment and a supporting plan around monitoring their weight, which included regular weight checks and additional snacks and enriching meals with butter and cream. The health care needs of people unable to leave the home are managed by visits from local health care services, for example their own GPs and District nurses. People have the aids and equipment they need to support them in their daily living. All aids and equipment are well maintained, to makes sure they are fit for use. Staff said they are committed to delivering a good standard of care to people who live at the home. One person said, “ The staff and everybody have been wonderful.” One relative said. “ My mother is given a high level of support. Staff are always around and ask if mum was o.k.” We saw that staff respected people’s privacy and dignity. For example knocking on peoples bedroom doors before entering. Policies and procedures about medication are in place. Staff who deal with medicines have had appropriate training. This means that medications are looked after safely. Westholme DS0000033302.V370692.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. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Wherever possible people living at the home are encouraged and supported to make choices and decisions. This means that they are in control of their lives. EVIDENCE: Staff are clearly committed to providing a care service that is based on empowering people, supporting them to make decisions and take control of their lives. Staff had a good understanding of the individual’s needs and choices. They spoke about the importance of promoting independence and gave examples of how this works in practice. They were also knowledgeable about the reasons why some people with dementia may become distressed and gave examples of how they support people during these times. From discussions with people living at the home it is evident that they are consulted about what they want to do. Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 13 Daily routines are flexible, for example people can get up and go to bed when they choose. They can choose how and where to spend their day, either in their rooms or the communal areas. We were told that there is a ‘pen’ picture/life history in each person’s care plan. We saw these in the plans we looked at, they were very detailed and informative about the individual. This information is used to plan activities according to people’s preferences and abilities. We saw people painting and playing bingo. Staff asked people if they wanted to join in and it was clear they could choose whether or not they wanted to. The cook has completed an advanced training course about nutrition and had a very good understanding of the importance of this for older people. She knew what people’s dietary likes and dislikes were and took this into account when planning meals. We saw the cook serving lunches to people; this meant that staff were free to help people who needed it, this was done discreetly. The tables were nicely set with tablecloths, napkins, and condiments. People were offered a cold drink with their meal and a hot drink afterwards. The meal was nicely presented and looked appetising. There was a choice of two hot meals and alternatives were available if people did not want what was offered. People living at the home spoke highly of the meals. A cooked breakfast is available and there is a choice at both the lunchtime and teatime meal. Snacks and drinks are available 24 hours a day. People and visitors told us that: • There were enough activities that they could join in with and gave examples of bingo, quizzes and outdoor activities. • ‘There’s always something to do’ • ‘Activities are arranged but I don’t always join in’ • The meals were good. Relatives and visitors can come at any time and are welcomed by staff. We saw staff offering visitors drinks. Westholme DS0000033302.V370692.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are procedures and systems in place for responding to complaints and keeping people safe. EVIDENCE: A complaints procedure was seen on the notice board in the reception area. We looked at it and found that it might not be easy for all people to understand. We talked to the care officer about this and were reassured that it would be revised. There have been two complaints since the last inspection. They were about care related issues and have been investigated and responded to. Information from people living in the home and their visitors told us that they knew what to do and who to talk to if they had a complaint or any concerns. The home has policies and procedures in place relating to safeguarding people. Care and domestic staff were clear about how to respond to any suspicion or allegation of abuse and were able to describe the different types of abuse. Staff training on safeguarding adults is ongoing and it is always talked about at staff meetings to keep it at the forefront. Westholme DS0000033302.V370692.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are involved in the refurbishment of the home, so that they live in comfortable surroundings that meet their needs. There are health and safety systems in place, to make sure people are safe. EVIDENCE: We were told in July 2008 that work to refurbish the home would be starting at the beginning of August 2008. This work had started when we visited. We were told that this would include new carpets in some communal areas, refurbishing all of the bedrooms and improving the lighting. A new assisted bath has already been fitted, it looked nice and people said they liked it. Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 16 At the last inspection we were told about two occasions when cars had crashed through a fence narrowly avoiding bedrooms on the ground floor. We were told that senior management is looking at the possibility of erecting a metal perimeter fence. Returned survey from people living at the home said that the home was always clean. All the areas that we saw were clean and tidy and there were no offensive odours. Care and domestic staff had a good understanding of infection control. There was liquid soap and disposable towels in all areas where clinical waste and bodily fluids are handled. Changes made after the last inspection mean that staff no longer hand sluice soiled linen and are now using water-dispersible bags. This means that the risk of cross infection is reduced. Westholme DS0000033302.V370692.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are supported and protected by the recruitment polices and practices at the home. EVIDENCE: When we visited there were thirty-three people living in the home. During the day there are five care staff on duty supported by two care officers. At night there are only two staff on duty. We were told that in an emergency the night staff should contact the ‘on call’ staff or a principal unit manager. People living in the home and staff told us: • There is usually enough staff available to us. • Most of the times there is enough staff. We looked at the files for two staff that had been employed since the last inspection. They showed that all the required checks were completed before they started work. One of them told us they had not been allowed to start work until the checks had been done, they included two written references, POVA (Protection of Vulnerable Adults) first and CRB (Criminal Record Bureau) checks. Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 18 We were told an induction programme based on the Skills for Care Common Induction Standards is in place for all new staff. We were told that 90 of staff has achieved an NVQ (National Vocational Qualification) at level 2 or above. Staff • • • • • • told us about training they had done which included: Dementia Medication Safeguarding Infection control The Mental Capacity Act Dignity in care homes Westholme DS0000033302.V370692.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed and run in the best interests of the people who live there. EVIDENCE: The manager was not on duty when we visited. She returned in October 2007 after a year’s sabbatical. She is in the process of making an application to be registered with us. She has commenced NVQ Level 4 in management that would give her the knowledge to help her in her role as manager. The management approach encourages people, relatives and staff to be involved in the day-to-day running of the home. We were told by staff that: Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 20 • • “I have regular supervision and appraisal and the manager has an open door and is approachable.” “The manager and care officers give support all the time. I have every respect for the team who will advice and give support to things I need to discuss.” There is a good quality assurance system in place so that people and their relatives and others involved in the home can give their views of the service the home provides. The information is used to develop an action plan for future development work. Staff told us that the management team is committed to getting people’s views and opinions about life in the home. Regular meetings take place and minutes are available to people and their relatives. The home holds money for some people. When we looked at the records and they were up to date. All transactions were listed, and receipts were available for money spent on people’s behalf. The maintenance records we looked at were up to date and showed that equipment is maintained and serviced at the required intervals. We saw that risk assessments were in place for the building work that was in progress. We saw a notice informing people and their visitors of the work being done in the home and the safety measures in place. There are systems in place for recording and monitoring accidents, so that any possibility of accidents can be recognised and an arrangement put in place to reduce the potential risk. Westholme DS0000033302.V370692.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 3 x 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 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 X 3 3 Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 22 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 Westholme DS0000033302.V370692.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Westholme DS0000033302.V370692.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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