Inspection on 10/10/06 for WCS - Westlands

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

WCS - Westlands 29/12/05

WCS - Westlands 28/07/05

WCS - Westlands 03/11/04

WCS - Westlands 26/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE WCS - Westlands Oliver Street Rugby Warwickshire CV21 2EX Lead Inspector Mr Kevin Ward Key Unannounced Inspection 10th October 2006 08:00 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 WCS - Westlands DS0000004270.V313942.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. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service WCS - Westlands Address Oliver Street Rugby Warwickshire CV21 2EX 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) 01788 576604 01788 535553 Warwickshire Care Services Limited Care Home 38 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (27) of places WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Westlands is a three-storey purpose built care home. The home is currently owned and managed by a voluntary organisation, Warwickshire Care Services. Westlands underwent a major refurbishment in 1998. The home is located close to Rugby town centre, bus and railway stations and is located within a community, which provides local services such as shops, public houses, restaurants, coffee bars and clubs. Accommodation is located on three floors. Each floor has one lounge and a dining area with integral kitchenette. All bedrooms are single some have ensuite facilities. Service users can furnish and redecorate to their own taste if they wish. The gardens are attractive, well maintained and accessible. There is a variety of garden furniture including sun umbrellas and tables. A ramp allows easy access to the patio area. The home provides both long-term residential care for 38 frail older people, and a day care facility, which accommodates up to eight older people. This inspection focused on assessing the main key Standards and on reviewing progress to meet the requirements that were made at the last inspection. As part of the inspection process the inspector reviewed information about the home that is held on file at the Commission such as notifications of accidents and incidents. 13 people completed questionnaires that asked questions about life at the home and 1 visitors questionnaire was returned as well. The inspection involved seeing most of the people living at the home and case tracking three people. Case tracking involves looking closely at people’s care records and checking how their needs are being met in practice. The inspection also involved talking with a number of the support staff on duty, in addition to the housekeeper, the administration officer and the manager. A number of records, such as care plans, staff files and fire safety records were also sampled for information as part of this inspection. The fees for the home range between £375 per week and £395 per week for a Residential Care placement and £468.00 per week for a placement on the dementia care unit. An extra charge of £15.00 per week is charged for an en suite room. The fees do not include the purchase of personal items such as WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 5 newspapers, personal toiletries, clothing, private chiropody and hairdressing. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? Staff at the home have been provided with dementia care training so that they are better equipped to meet the needs of the people living in the dementia care unit. PEG tube protocols are now in place and staff involved in managing PEG tube feeding have been trained by a district nurse to support staff safe practice in this area of care. There is evidence that pressure area care is being carried out appropriately. The care plan of a person with pressure area care needs was up to date and records were in place confirming that various aspects of essential care are being carried out. A new controlled drugs register is now in place. The manager reports that only one person currently receives controlled drugs. The record has been properly filled in by staff to account for medication. A sample of recent medication WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 7 records were seen. The records indicate that staff now use the appropriate codes to explain the reasons why a person may not have received medication (e.g. refused) and record further explanations on the rear of the form. Training information provided by the manager and comments by staff indicates that staff are provided with a good range of training courses to equip them for their work. What they could do better: There remains a need to review and update information about the home and ensure that it is passed to all new people before they move in so that they are better prepared for their move to the home. As at the last inspection, the home is still behind with some monthly care plan reviews. These reviews are an important means of ensuring that changes in people’s needs are recognised and addressed by staff. The manager indicated that this would be addressed as a matter of priority now that the staffing situation has improved and following the imminent appointment of a new deputy manager (care manager). There is a continued need to improve the activities and social outlets for people in the home. Recent action has been taken by the manager to consult people about the activities and outings they would like at the home. The manager said that an additional staff member would shortly be provided to develop activities at the home. The manager reported that a senior manager within the organisation periodically carries out monitoring visits. However the reports of these visits have not been sent to the home and there is no evidence to suggest that issues identified by the visits are addressed. There is a requirement to take prompt action to apply for the manager to be registered as the manager has been in post since April 06 and an application has yet to be submitted. There have been occasions when staffing has been insufficient to attend to the care whilst maintaining care plans up to date. Hence there is a need to ensure that suitable staffing levels are maintained to ensure that the work of the home is carried out effectively. The manager is recommended to keep staff training records up to date to assist the home to help ensure that gaps in training needs are easily identified and met and to demonstrate that staff are being properly trained for their jobs. Overall suitable checks are in place for maintaining fire safety in the home, however it is recommended that night staff are included fire drills from time to time. Please contact the provider for advice of actions taken in response to this WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 9 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 WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is adequate. People’s needs are assessed before they move in. There is scope for improving the levels of information made available to people better prepare them when they move to the home. EVIDENCE: People’s files were seen to contain written assessments provided by social workers, as evidence that the home seeks proper information about people’s needs before they move in. Comments by several people at the home confirmed that they (and / or their relatives) had been given information about the home when they were moving in so that they knew what the service had to offer them. However in the questionnaires that were sent to people as part of the inspection process, 6 people said that they did not receive as much information as they would have liked before they moved in. Several people also confirmed that they had been provided with the opportunity to visit the home, or had asked their relatives to visit on heir behalf to view the home before they moved in. A lady who had recently moved to the home confirmed that she had just attended a review meeting to confirm that she was happy to WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 11 remain at home. The manager explained that information about the home (Statement of Purpose and service user guide) are still being updated and that this work will be completed shortly. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, & 10 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is good. Overall people are provided with the support they need to meet their needs. The home is behind with some care plan reviews and there is scope for developing care plans to provide a more comprehensive picture of the people at the home. EVIDENCE: Three people’s care plans were checked as part of case tracking (case tracking involves examining people’s care plans and checking that there needs are met by the home). The care plans are formatted in a way that prompts staff to record information about a good range of care needs. Some of the information e.g. people’s life histories, was seen to be of variable quality but overall adequate guidance was recorded to support staff to meet people’s essential needs. The manager stated that she has plans to improve the level of information in the care plans so that they are more comprehensive and provide a clearer overall picture of people. The manager explained that the home was behind with some of the monthly reviews of care plans, due to recent staffing shortages that had now been addressed. This was verified in conversations with staff at the home who confirmed that the staffing situation had improved, WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 13 releasing time to catch up with reviews of care plans. The manager explained that priority had been given to reviewing the care plans of people with higher support needs, where their needs tend to change more frequently, so that essential information was in place to ensue that these people received the correct care. This was borne out by the dates recorded in the sample of care plans that were examined. Monthly reviews include a section in the care plan for recording the views of people about different aspects of the service they receive. A different question is considered each month and the person’s answer is recorded, as evidence that their views have been sought at the time of their care review. Care plan records were seen to include risk assessments for a wide variety of aspects of care and suitable guidance is in place to enable staff to carry out the correct care to reduce any risks identified. For example suitable guidance was seen to be in place to address one persons pressure area needs. The records of the care given to this person indicated that the guidance was being followed and that the correct care was being provided and monitored. Appropriate pressure relieving equipment had been made available for this person and the district nurse was appropriately involved in her care. Discussions with staff indicated a good understanding and awareness of this persons care needs. Comments by people living at the home confirmed that they are supported to gain access to support from health professionals, such as GP, dentist, optician, district nurses and chiropodists. Appropriate action had been taken to refer one person for an Occupational Therapist assessment following a change in her needs, and the equipment required to help her to transfer safely and comfortably. A PEG (Percutaneous Endoscopic Gastronomy – means of artificial feeding) feed protocol was seen to be in place that had been appropriately signed by a nurse, providing the correct procedures for staff to follow. Comments by staff confirmed that training has been provided by a community nurse to support safe practice in this area of care and this was verified in training information provided by the manager. Lockable trolleys are in place for the safe storage of people’s medication. The contents of the trolley were examined and found to be tidy and well ordered. Comments by a member of staff demonstrated a sound awareness of medication procedures. Comments by staff confirmed that they are provided with medication training and are not allowed to give out medication until they have been deemed competent to do so. The organisation has designed a new assessment tool for more formally checking that staff hold a clear understanding of good medication practices. The manager said that the new assessment would be introduced very shortly. Medication is being recorded into the home so that it can be accounted for. The manager explained that a visiting manager carries out monthly medication audits at the home so that any shortfalls in the medication systems can be addressed. Such an audit took place on the same day of the inspector’s unannounced visit. A sample of recent medication records were examined. The records indicate that staff are aware of WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 14 good recording procedures and make appropriate use of recording codes and make notes where needed, e.g. people refuse to take the medication. A new controlled drugs register was seen that had been appropriately filled in to account for the medication of a person living at the home. Comments by the people living at the home indicated a positive view of the staff and of the care that is provided. This was also reflected in the comments recorded in questionnaires returned by people as part of the inspection process. Staff were seen to be polite and friendly and to approach people with courtesy and respect. People confirmed that they could go to bed and rise when they please. One person said “I usually have a word with a member of staff when I am getting tired and we come to some arrangement that I am happy with”. Everyone at the home was dressed in suitable well-laundered clothing and looked well groomed, indicating that people are cared for and supported to retain a pride in their appearance, which is important for a good self-image. All personal care tasks were carried out in private behind closed doors showing a suitable regard for people’s privacy and dignity. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is adequate. People are supported to make choices and are provided with food they enjoy. The rating for this group of Standards is compromised due to the continued shortage of activities in the home, although there is evidence to suggest that improvements are planned to take place in this regard. EVIDENCE: Comments made by people living at the home and feedback in the questionnaires returned by people indicate that generally they feel they are appropriately consulted about issues that affect them, such as their care needs and the food in the home. People said that there was not a lot of planned activities in the home and some indicated they would like to get out more. Some people enjoy games of cards and dominoes together and one lady said that she particularly enjoys doing the crossword. Occasional entertainers also visit the home and people from the pet therapy service visits with dogs for people to see and stroke. An off duty member of staff brought her small dog in for someone to see on the day of the inspectors visit. Some people were seen to spend time together in the main lounge areas and others were seen to go to WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 16 their own rooms. One lady said “the days can seem long sometimes”. One man stated that he is free to go out alone to buy his paper when he wants to do so, indicating that people are encouraged to retain their independence to the extent that this is possible. A number of people commented that they had recently had meetings with the manager aimed at improving activities and outings at the home. The manager confirmed that this was the case and notes of these meetings were seen, including a wide range people’s ideas and suggestions. The manager stressed a commitment to improving the level of activities and following up people’s ideas and said that an additional member of staff would be added to the rota shortly to support activities in the home. Comments by staff in the dementia care unit indicated a satisfactory awareness of people’s needs and interests. The staff on duty confirmed that they had been provided with dementia care training. Discussions with people confirmed that where they wish to do so they can receive visits from a catholic priest to take communion. A Church of England service also takes places at the home on a regular basis. Currently there is no one with other religious needs living at the home. The manager expressed a commitment to supporting people of other religious beliefs in the event that they should move into the home. People confirmed that they are free to receive visitors when they wish, in keeping with the home’s visitor’s policy. A visitor’s questionnaire that was returned as part of the inspection process indicates that relatives visiting the home are made to feel welcome and kept informed of important matters. A choice menu is in place at the home and people confirmed that staff ask them what they want, in preparation for the next day. Comments by people confirmed that overall they are very satisfied with the food provided at the home. Recent concerns expressed about the quality of a particular meal had been appropriately followed up by the manager. One lady explained that she had been offered an alternative to the main menu recently when she declined the main food options. The menu is also periodically reviewed with the people living at the home to take account of any changes they want to make to it. The dining areas provide comfortable, pleasant areas for people to sit and eat in small groups. Sometimes people to choose to eat in their rooms or in front of the TV where they wish to do so. Records were seen to be well kept detailing the food and drinks taken by a lady who was poorly in bed to ensure that her nutritional needs were met properly. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is good. People are encouraged to raise their concerns and complaints so that they can be addressed and staff are trained to recognise and report suspicions of abuse so that people are safeguarded from harm. EVIDENCE: Comments by people at the home and confirmed that they are aware how to complain and have confidence in the manager to listen and deal with their concerns. This is also reflected in the responses in the questionnaires that were sent to people as part of the inspection process. There have been no complaints made about the home to the Commission for Social Care Inspection and the manager stated that there have been no recent formal complaints made at the home. A book is available in each of the three living areas in the home that people can choose to use to comment or complain if they wish to do so. Comments by people indicate that any concerns are usually addressed at an early stage before they develops into complaints. Notes of previous complaints are held in a loose-leaf binder and there is currently no log, which would make it easier for tracking the progress of complaints investigations and their eventual outcome. As previously noted people have the opportunity to comment on aspects of the home as part of the quality assurance system, which also provides them with another opportunity to raise any concerns, they may hold. Discussions with staff confirmed that they are provided with access to the prevention of adult abuse policy and provided with training on this important WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 18 subject area. This was confirmed in staff training information provided by the manager. A member of staff confirmed that the training included definitions of abuse, which help staff to recognise issues of abuse as well as reporting procedures so that any concerns can be investigated. There have been no adult abuse investigations held at the home during the last year. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is good. People are provided with clean, comfortable accommodation that is well equipped to meet their personal needs. EVIDENCE: Overall the home provides good disability access throughout the building. The corridors are wide enough for wheelchair users to use and the bathrooms, shower rooms and toilets are quite spacious and well equipped to meet the needs of people with disabilities. The main entrance is ramped providing good wheelchair access and a lift is in place to enable people to move between floors. The toilets are equipped with raised seats, grab rails and specialist equipment, to enable staff to safely assist people who have mobility problems. Where necessary the home has arranged for people to receive specialist equipment, e.g. mattresses, in keeping with their care planned needs. One person had an occupational therapist assessment pending to assess her needs for more specialist equipment. WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 20 Overall the home is maintained in good decorative condition. There is evidence of a rolling programme of redecoration in the home and the manager explained that 10 bedrooms are to be decorated very shortly. The lounge / dining areas are attractively decorated and furnished with domestic style furniture to give the place a homely feel. People are encouraged to bring in items of their own furniture to personalise their own rooms, the details of which are recorded in their care plan. The home is clean and no unpleasant odours were apparent anywhere in the building. The responses in questionnaires confirm that people are happy with the good standard of cleanliness in the home. Comments by the housekeeper indicate that suitable arrangements are in place for managing continence laundry, including red dissolvable wash bags, individual laundry hampers and protective clothing, which is situated in various areas of the building making it easier for staff to access. A suitable clinical waste contract is in place at the home. WCS - Westlands DS0000004270.V313942.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18,29 and 30 Overall the home provides good disability access throughout the building. The corridors are wide enough for wheelchair users to use and the bathrooms, shower rooms and toilets are quite spacious and well equipped to meet the needs of people with disabilities. The main entrance is ramped providing good wheelchair access and a lift is in place to enable people to move between floors. The toilets are equipped with raised seats, grab rails and specialist equipment, to enable staff to safely assist people who have mobility problems. Where necessary the home has arranged for people to receive specialist equipment, e.g. mattresses, in keeping with their care planned needs. One person had an occupational therapist assessment pending to assess her needs for more specialist equipment. Overall the home is maintained in good decorative condition. There is evidence of a rolling programme of redecoration in the home and the manager explained that 10 bedrooms are to be decorated very shortly. The lounge / dining areas are attractively decorated and furnished with domestic style furniture to give the place a homely feel. People are encouraged to bring in items of their own furniture to personalise their own rooms, the details of which are recorded in their care plan. The home is clean and no unpleasant odours were apparent anywhere in the building. The responses in questionnaires confirm that people are happy with the good standard of cleanliness in the home. Comments by the housekeeper indicate that suitable arrangements are in place for managing continence laundry, including red dissolvable wash bags, individual laundry hampers and protective clothing, which is situated in various areas of the building making it WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 22 easier for staff to access. A suitable clinical waste contract is in place at the home. EVIDENCE: Comments by staff and the manager explained that there have been recent pressures on the staffing rota that have impaired the ability to keep up with administrative tasks such as care plans and stretched the capacity of staff to respond as promptly to people as they would have liked to. Comments by the people living at the home and the staff indicated that this problem had been resolved. The manager explained that recent staffing pressures had now been alleviated by using some agency workers whilst new staff were being recruited. An examination of the rota confirmed that where agency staff had been used they had been placed on different living units, alongside more experienced permanent staff. Two recent staff recruitment files were examined and found to contain evidence to confirm that suitable recruitment procedures are being followed. In both cases the home had taken up references and Criminal Record Bureau checks as part of the betting procedure to ensure that suitable vetting procedures are in place at the home. The organization has an extensive induction procedure for new staff and runs “enabler training” to provide some of the underpinning knowledge and skills necessary for staff to go on and complete National Vocational Qualifications (NVQ’s). Discussions with a number of staff on duty confirmed that they had all received access to a good range of ongoing training, including health and safety related training and care courses, such as dementia care training. Staff training records were not up to date at the time of this site visit. Following the site visit the manager produced a summary of training provided at the home. This information supports the comment made by staff and indicates that a suitable range of training opportunities are made available to equip staff to carry out their work. The manager agreed to keep this information updated to serve as the basis for the home’s training plan. WCS - Westlands DS0000004270.V313942.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34, 35 and 38 This judgment has been made using the available evidence, including a visit to the service. The judgement for this outcome group is adequate. The home seeks the views of people to influence the service provided at the home. Management monitoring systems need to be made more robust to ensure that service shortfalls are promptly identified and addressed. EVIDENCE: The current manager has been in post since April 06. The manager explained that she has completed the relevant application forms to be registered with the Commission for Social care Inspection. These forms have not yet been submitted by the organisation so that the registration process can go ahead. The manager has previous experience of managing a care home and stated that she is in the process of completing the NVQ 4 Registered Managers Award. The home operates various quality assurance measures. As noted previously people are asked to complete a quality assurance question each month and the WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 24 results are fed into the annual review for the organisation. This then feeds into an action plan to address common issues across the organisation. There is no evidence to confirm that the home is being properly monitored by senior managers from within the organisation. The manager reports that she has witnessed several visits from a senior manager to carry out monitoring visits, however no reports have been sent to the home. Hence the findings of these visits and actions taken to address any shortfalls at the home are unclear. Comments by the manager and the administrator confirmed that no one at the home acts as appointee for people. People’s relatives or advocates take on this role. Expenditure records were seen to be in place to account for people’s personal expenditure. The administrator signs each transaction and the manager confirmed that she also monitors the record. A financial officer from within then organisation carries out periodic audits of the home’s finances, including people’s personal monies. A copy of a recent report was seen on file at the home. Recent fire safety records were checked. The record shows that the housekeeper normally conscientiously carries out the fire alarms on a weekly basis. One test had recently been missed due to the housekeeper’s absence on annual leave. The manager said that she would ensure that arrangements are put into place to ensure that this duty is carried out by someone else when the housekeeper is not available in future. Entries in the fire safety log indicate that emergency lights are routinely tested and that safety drills are carried out, however there have been no recent drills involving night staff at the home. WCS - Westlands DS0000004270.V313942.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 1 3 x x x x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 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 2 x 2 x 3 x x 2 WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4, 5 Requirement The Statement of Purpose and Service User Guide must be reviewed. (Outstanding from 31.03.04) 2 OP7 15 Care plans must be up to date and reflect the current needs of individual residents. These must be reviewed monthly as a minimum. Outstanding from 31/3/06 The registered provider must ensure that suitable and varied social and leisure opportunities are available to residents. Outstanding from 31/3/06 4 OP27 18 The registered provider must ensure that there is consistently sufficient staff on duty during all shifts. 30/10/06 30/11/06 Timescale for action 31/12/06 3 OP12 16 21/11/06 WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 27 5 OP30 18S 2 The registered provider must ensure that there are accurate training records for all members of staff, indicating past and present training. 30/11/06 6 OP31 9 Outstanding from last inspection 28/2/06 The Resisted Person must ensure 14/11/06 that the manager applies to be registered with the Commission for Social Care Inspection. The Registered person must ensure that monitoring visits are carried out and that reports containing the outcomes of the visits are sent to the manager and retained at the home. 30/11/06 7 OP33 26 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 OP1 Good Practice Recommendations It is strongly recommended that all new people referred to the home be given suitable information (service user guide) at an early stage to help to prepare them for their move. The manager is recommended to set up a complaints log for the efficient tracking and monitoring of complaints at the home. It is strongly recommended that a fire drill takes place involving the night staff. 2 3 OP16 OP38 WCS - Westlands DS0000004270.V313942.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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. 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