Inspection on 20/06/07 for The Westbury Nursing Home

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Westbury Nursing Home 14/06/06

The Westbury Nursing Home 08/11/05

The Westbury Nursing Home 01/07/05

The Westbury Nursing Home 21/07/04

The Westbury Nursing Home 27/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Westbury Nursing Home Falcondale Road Westbury On Trym Bristol BS9 3JH Lead Inspector Wendy Kirby Key Unannounced Inspection 20th June 2007 09:30 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 DS0000020344.V344943.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. DS0000020344.V344943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Westbury Nursing Home Address Falcondale Road Westbury On Trym Bristol BS9 3JH 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) 0117 9079971 0117 9146665 Westbury Care Limited Mrs Penelope Anne Brown Care Home 73 Category(ies) of Old age, not falling within any other category registration, with number (73) of places DS0000020344.V344943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate 73 Persons over 50 years of age receiving nursing care. Manager must be a RN on Parts 1 or 12 of the NMC register Date of last inspection 14th June 2006 Brief Description of the Service: Westbury Nursing Home is operated by Westbury Care Limited. The home is privately run and provides accommodation for 72 people who require nursing care. Accommodation is provided on three floors. The home has 67 single rooms with en suite facilities and four shared rooms with en suite facilities. The home is set within its own grounds and is within a short walking distance from the village of Westbury on Trym. There are local shops and amenities nearby plus a bus route into the City centre. The cost per week to reside at Westbury Nursing Home will be from £520.00. Fees are reviewed annually and if care needs increase. This weekly fee does not include provision for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by accessing the Service Users Guide, which will detail the services and facilities available at the home. DS0000020344.V344943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over one day, as part of the annual inspection process. The inspector spent time throughout the visit talking to people who live in the home, relatives, the manager and staff members; a number of records and files were looked at, including care records, staff training records, and the complaints log and medication records. The inspector toured the premises accompanied by the maintenance man. Feedback was given on the outcome of the inspection. The inspector would like to thank all the people who took part in the inspection. Their enthusiasm and support was greatly appreciated. The atmosphere in the home was warm in manner; staff were respectful, good humoured and sensitive towards people living in the home within a relaxed, calm environment. What the service does well: Systems are in place to help ensure that there is consistency in assessing, planning, implementing and evaluating care at the required times. Staff have a good awareness of individuals’ needs and treat people in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. Meals are well presented and menus verify a healthy well balanced diet with a wide variety of choice. The home is comfortable, tastefully decorated and furnished to a very high standard. It provides a safe, peaceful and well-maintained environment for all people who use the service. Adequate staffing levels help to ensure that needs are met. Staffing levels are increased should the dependency levels of the residents change. The recruitment procedure serves to protect vulnerable people. The home is well organised and managed by an effective, stable management team that promotes the views and interests of all people who use the service. DS0000020344.V344943.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. DS0000020344.V344943.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 DS0000020344.V344943.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): 1,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and/or their families have all relevant information to make a decision about the nature of the home. People who wish to move into the home have their needs assessed prior to admission to determine the suitability of placement. They can be confident that staff will have the resources and skills to meet those assessed needs. EVIDENCE: An extensive information pack containing a service user guide and statement of purpose is made available to prospective clients and their families. The pack provides valuable information on the facilities and services available to people within the home. DS0000020344.V344943.R01.S.doc Version 5.2 Page 9 Pre-admission assessments are comprehensive covering all activities of daily living, a full health screen and personal history background. The prospective client, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. The manager through her assessments was able to demonstrate a good knowledge of the current people living in the home, their medical history, personal background and their subsequent needs. The inspector looked at six pre-admission assessments and the information gathered provided a sound benchmark of peoples ability and state of health prior to admission. People are encouraged to visit the home either for the day or perhaps for lunch dependent on their wishes. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. DS0000020344.V344943.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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The consistent practice regarding planning and delivery of care means that people can be sure that their health and personal care needs will be fully met. Because they are consulted about their health and personal care needs people can be sure their views and expectations will be considered. Safe systems of practice in receiving, storing, administering, and disposing of drugs protect people living in the home. People living in the home can be confident that staff have a good awareness of their needs and that they will be treated with dignity and respect. DS0000020344.V344943.R01.S.doc Version 5.2 Page 11 EVIDENCE: From the pre admission assessments the staff are able to develop a set of care plans based on identified needs. During the first months trial period the plans are reviewed weekly and developed accordingly. The inspector looked at eight care files. The information for each person was informative and useful enabling staff members to identify individuals and how to support their health and social needs including, psychological, emotional, and cultural needs which demonstrates that the home is holistic in its approach to the provision of care. Health care needs in the files included, wound care, nutritional, and pressure area risk assessments. With the exception of two care files, all documentation accurately reflected people’s current needs and evidenced consistency in assessing, planning and evaluating the care on a monthly basis. The two files identified as not been updated were updated by staff before the end of the inspection. The home conducts regular care review meetings for each person living in the home, which includes the involvement of family members and key worker wherever possible. This allows the opportunity to discuss and evaluate care plans and any issues or concerns they may have. Surveys indicated that relatives felt reassured that they were kept informed of important issues affecting their friend/relative in the home. Comments received included, “I am always contacted by phone if there are any problems”, “Senior staff always find time to inform me and are really helpful” and “On occasions the doctor has personally phoned us”. All staff demonstrated good relationships with individuals and were knowledgeable about the care needs of the people living in the home. Relatives were asked in their surveys if the home supports and cares for their relative as you would expect and/or agreed. Comments included, “My relative receives encouragement from staff” and “Many staff show concern and interest in the families too and are always making sure that we are ok”. Records of the General Practitioner (GP) visits and the outcomes were documented. Specialist referrals and visits from other professionals including, Physiotherapists, Chiropractors, Dentists and Opticians were also seen. The Inspector was informed that people are referred to a GP on admission to the home and an initial first visit is set up. Although not all GP’s conduct weekly visits to the home, good working relationships with GP’s have been formed and they will visit on request. Surveys confirmed that people living in the home receive the medical support they need. DS0000020344.V344943.R01.S.doc Version 5.2 Page 12 Surveys and discussions with relatives indicated that the care home meets the needs of the people living in the home and comments included, “My relative seems to have really settled in and actually seems to be more active and sociable” and “The home has lifted my relatives mood, she is more alert, put on weight and is mixing well with other people living in the home”. Policies and procedures for receiving, storing, administering and disposing of medications were examined and correct. There were photographs of each resident on their medication charts to help ensure that medication was dispensed to the correct person. The administration charts were legible and continuity of administration was shown with a signature from the person dispensing. Respecting privacy and dignity is included in the induction programme for all staff. Staff knocked on people’s doors before entering confirming respect for individual privacy and dignity at all times. Members of staff spoke respectfully about peoples needs and referred to them in the term of address that they preferred. All rooms have a telephone point from which people living in the home can make and receive calls. The manager and staff make every effort to establish people’s wishes concerning palliative care and any provision they would wish for by developing end of life care plans. The manager explained that the plans are sensitively completed with individuals and their families/significant others. Some families had chosen to take private time together to discuss their wishes and then pass the information on to the home so that a care plan could be devised. Plans were personalised and the information sought was well thought out and should help ensure that choices are respected. DS0000020344.V344943.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. 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. People who live in the home benefit from a varied activities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Encouragement and support from staff enables people living in the home to maintain good contact with family and friends and outside community resources. Evidence confirms that people’s choices, preferred daily routines and preferences are respected by staff at all times. People living in the home receive a varied and wholesome diet that they are able to influence. DS0000020344.V344943.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home has been working hard to develop a relatively new initiative to complete a social assessment of each person living in the home. It is a comprehensive document, which has enabled staff in the home to relate to people in a personalised way. It creates topics of conversation, encouraging life review and reminiscence, which will have meaning to that individual person. Daily routines are flexible within the home, people get up and go to bed when they like, have their meals in their bedrooms, go out when they wish and participate in activities they have a particular interest in. This was confirmed through documentation in care files and in discussion and through observation during the inspection. Some documentation on individual’s daily routines required more content to enable staff to be more aware of how people wish to live the lives they choose on a day to day basis. All surveys indicated that people living in the home are supported to do this. The home has a monthly residents meeting which are well attended and minutes are taken. These are circulated on the notice boards. In consultation with people living in the home the manager and activities coordinator develops a monthly timetable of activities and forthcoming events. A copy of this is placed in communal areas throughout the home, to ensure that everyone is aware of the planned activities. Regular activities include a weekly visit from an art teacher who has been visiting the home for six years. Musicians also visit the home on a regular basis including music played on the harp, acoustic guitar, and musical percussion. People are supported to satisfy their religious preferences. Local denominations visit the home monthly to provide a service, and local church volunteers visit alternate weeks to sing hymns with those who choose to attend. One relative stated, “It is reassuring to have staff of various cultures. Everyone I have seen is culturally aware and considers religion and customs in their care procedures of my relative”. Surveys in general confirmed that there was an adequate and varied amount of activities and outings arranged. The activities coordinator is relatively new and the inspector spoke with her about how her role was developing and new initiatives she has made since the last inspection. It was evident that the activity coordinator was enthusiastic about her roles and responsibilities. A record of activities provided and who has participated is recorded in an activities file with outcomes of whether the activities were a success and how much they were enjoyed. This is very good practice and will be a useful exercise in contributing towards the homes annual quality assurance. DS0000020344.V344943.R01.S.doc Version 5.2 Page 15 The home operates an open door policy for visitors. People are able to see visitors in the privacy of their rooms and there are several semi-private seating areas around the home and in the garden. Surveys stated, “I always feel welcome when I visit” and “The staff are very happy and friendly”. Although there is a daily menu plan each person in the home is visited daily in order for him or her to choose what he or she would like to eat. On some days the catering staff can prepare up to fifteen different choices. All food is freshly prepared in the home on a daily basis including, cakes, pastries, bread, soup and fruit salad. The size and layout of the dining rooms makes it possible for everyone to enjoy the social advantages of dining together. Staff had used their expertise and knowledge of the peoples, personalities, preferences and ability to eat independently, when seating them for lunch. The dining rooms were light, spacious and the tables were attractively laid with tablecloths and flowers. Residents that required assistance with eating their meals were supported by staff members, this was performed in a respectful, sensitive way, for example without rushing the residents and staff were sat at the same level as the resident. Staff were polite and helpful when serving the meals. DS0000020344.V344943.R01.S.doc Version 5.2 Page 16 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. People who use the service feel that they are listened to and that the service responds appropriately. Staff training and awareness in the Protection of Vulnerable adults helps to ensure peoples safety. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the home, which means people will know how to obtain the required information if they want to make a complaint. The complaints policy and procedure is detailed and contains all the required information. Documentation of complaints received since the last inspection were examined and confirmed that policies and procedures were followed correctly and that the complaints were dealt with and resolved effectively and efficiently. DS0000020344.V344943.R01.S.doc Version 5.2 Page 17 Some issues or concerns are discussed at the residents meetings, which are well attended by the relatives in other instances concerns are dealt with on the spot. People stated, “Usually a conversation with senior staff dissolves and concerns” and “Concerns are taken fully on board and sorted very quickly”. There are procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse’ including the Local Authority “No Secrets” document. The staff handbook and induction training provides education on topics for whistle blowing, management of aggression and bullying. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. The inspector was informed by the manager that the organisation actively promotes staff training and education in these areas, all staff are encouraged to attend training in dealing with difficult behaviours and protection of vulnerable adults. Staff training records evidenced this commitment. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of the protection of vulnerable adults from abuse. DS0000020344.V344943.R01.S.doc Version 5.2 Page 18 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): 19,21,25,26 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-maintained and is decorated and furbished to a very high standard. It provides a safe, homely, peaceful environment for people who use the service. The welfare of the people who use the service may be compromised by the lack of adequate ventilation in some areas of the home. The home is a clean, pleasant and hygienic place to live in. EVIDENCE: Westbury Nursing Home is situated close to local facilities and amenities. DS0000020344.V344943.R01.S.doc Version 5.2 Page 19 The light and spacious communal areas of the home are open plan, with various adequate seating areas for everyone. Open plan areas on both floors create a perfect atmosphere for dining with attractively laid tables. The upstairs floor is also open plan with a mezzanine that overlooks the ground floor lounge/diner. A glass ceiling offers plenty of light to the dining area. An extension has been recently built providing five additional bedrooms with en suite facilities and a large conservatory. The home is on three floors, with level access to all via a passenger lift. The inspector walked around the inside of the home with the maintenance man and viewed some of the bedrooms, bathrooms and sluices. The home continues to update, refurbish and redecorate rooms as and when required to a very high standard. Rooms have en suite facilities provided and communal bathing areas; showers and toilet facilities are located throughout the home. All areas of the home are tastefully decorated and well maintained. Great attention has been given to ensure that all areas are homely. People are supported to personalise their bedrooms with pictures and ornaments and they are able to bring items of furniture should they wish. Everyone was making full use of these areas and their bedrooms throughout the inspection. At the inspection conducted in June 2006 several people including those living in the home, visitors and staff complained about some areas in the home being too hot. During the inspection it was noted that large industrial fans had been placed around the home. The inspector met briefly with the registered provider who confirmed that various companies had been contacted of which some had visited the home to discuss options of providing air conditioning systems within the home. The provider appreciated how the warm spell was affecting people in the home and said that consultation would continue in order to make adequate provision for all concerned. Evidence was gathered throughout this inspection by talking to people in the home, by the comments received in the surveys and from the minutes of meetings attended by people living in the home. It is apparent that the situation remains unresolved. The inspector also found some parts of the home very warm and stifling during the inspection. Comments received from people living in the home and relatives included, “At times it can be very hot in some areas, perhaps this could be improved”, “Fans in communal rooms are not adequate at present during the hot weather” and “Please do something about the heat upstairs”. DS0000020344.V344943.R01.S.doc Version 5.2 Page 20 Staff confirmed that they were aware of the importance to particularly encourage and maintain an adequate fluid intake for all people living in the home during the warm months and as mentioned previously the industrial fans do offer some light relief. The situation was discussed with the manager and a requirement will be made for the registered provider to continue to investigate alternative ventilation provision for all people who use the service. The home was clean and free from unpleasant odours. The home employs a large team of domestic staff on a daily basis who have an allocated housekeeper. One relative said, “The standard of cleaning is very good”. DS0000020344.V344943.R01.S.doc Version 5.2 Page 21 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. Adequate staffing levels help to ensure that people’s needs are met. People who use the service are supported and protected by the homes recruitment policy. Staff are trained and people living in the home can be assured that staff will have the skills and resources to meet their needs. EVIDENCE: The manager confirmed that staffing levels are indicative of the needs and levels of care required twenty-four hours a day and those levels of staff would rise should dependency levels increase. People who live in the home felt that in general staff were available when they needed them, one person felt that, “Occasionally response for assistance has not been forthcoming”. DS0000020344.V344943.R01.S.doc Version 5.2 Page 22 Comments from surveys were positive about the staff in the home and included, “Staff show affection and kindness”, “The dedication of the staff to meet the needs of the residents is much appreciated” and “My relative gets on well with the staff and seems to be content”. The inspector spent some time throughout the day sitting in the communal areas observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner, good humoured and sensitive towards people within a relaxed, calm environment. Individual members of staff were spoken with and all staff demonstrated a very caring, committed attitude to their roles and responsibilities in ensuring they provide quality of care to the people who use the service. A robust recruitment policy and procedure is in place and the files inspected showed all the appropriate documents and checks were in evidence. CRB disclosures are being retained until the inspector has examined them. There is an induction programme, which covers all mandatory training, including Fire, Manual Handling, and Health and Safety. The home continues to support their staff with NVQ training and the enrolling programme continues. The manager and staff are conscientious in attending training relevant to the care needs of the residents, including updates on diabetes and wound care/skin care management, dementia care and how to meet the needs of residents with depression and anxiety. A training matrix had been developed and the inspector was able to see that all mandatory training including manual handling was undertaken and course dates had been organised for the future. DS0000020344.V344943.R01.S.doc Version 5.2 Page 23 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. Needs and best interests of people living in the home are central to the management approach in the home. Good accounting methods are adopted and policies and procedures are followed correctly when handling personal money. The health and safety of all people who use the service is protected and promoted. DS0000020344.V344943.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs Brown has been the manager at Westbury for five years. She has a dedicated team who continue to work with her to try and ensure that the highest standards of care are achieved and maintained. She is a registered general nurse and demonstrates a good understanding of the needs of the individuals living in the home. Staff stated that the manager was very approachable and gives good direction and supports them. There was a high degree of satisfaction expressed by all of the people who use the service during the inspection and comments included, “The home is much more like “a home” than many institutions I have visited”, “The home provides a safe secure environment and also encourages relatives participation” and “I will be so pleased if this level of care continues”. The policy and procedure for holding peoples personal money was examined and four individual accounts were looked at. It was evident that good accounting methods are adopted which account for all transactions documented and receipts for sundries were available to see. Some of the Health and Safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment and emergency lighting. The homes records showed all necessary service contracts were up to date including, gas and electrical services and the passenger lift. DS0000020344.V344943.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 X X X 2 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 X 3 DS0000020344.V344943.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP25 Regulation 23 (2) p Requirement 23 (2) The Registered person shall having regard to the number and needs of the service users ensure that(p) ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by service users. The registered provider must continue to investigate alternative ventilation so that people’s welfare and comfort is promoted. Timescale for action 12/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000020344.V344943.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 DS0000020344.V344943.R01.S.doc Version 5.2 Page 28 - 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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