Inspection on 12/06/07 for West Court Lodge

This inspection was carried out on 12th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Court Lodge 10/08/06

West Court Lodge 28/02/06

West Court Lodge 11/05/05

West Court Lodge 02/12/04

West Court Lodge 01/06/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 West Court Lodge 6 West Street Scarborough North Yorkshire YO11 2QL Lead Inspector Pauline O`Rourke Unannounced Inspection 12th June 2007 09:30 West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 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 West Court Lodge DS0000007829.V335851.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 Adults 18-65. 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. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Court Lodge Address 6 West Street Scarborough North Yorkshire YO11 2QL 01723 507256 01723 501 656 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Mrs Catherine Rayner Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (16) West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category MD(E) for current service users who reach the age of 65 years whilst resident in the home and whose needs can still be met by the home. 12th June 2007 Date of last inspection Brief Description of the Service: West Court Lodge is registered to provide residential social and personal care for 16 adults with mental health problems. The registered provider is Care UK Mental Health Partnership Limited (Arc Healthcare Limited) and the registered manager is Catherine Raynor. There are five floors with people’s accommodation located on all floors. The main lounge is on the ground floor and the dining room on the lower ground floor. The home does not have a passenger lift and is therefore only considered suitable for people who are fully ambulant. All of the bedrooms are for single occupancy. The home is conveniently situated for all main community facilities including the public transport network. The home does not have any grounds but is located adjacent to a public park. On-road parking is readily available for visitors. The current scale of charges for service users range from £317 to £417 a week. This does not include additional charges made, for example, for hairdressing, private chiropody and some personal toiletries. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire. Comment cards were returned from, people living at West Court Lodge, healthcare professionals, social care professionals and relatives. A visit to the home carried out by one inspector that lasted for five and a half hours. During the visit to the home seven people, three staff and two visitors were spoken with. Care records relating to four people, four staff members and the management activities of the home were inspected. Care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at West Court Lodge for the people living there. The manager was available to assist throughout the visit for feedback at the close. What the service does well: People who come to live at West Court Lodge have all of their needs fully assessed before moving in. People are only admitted when the staff are confident they can meet their needs. Everyone who lives at West Court Lodge has a care plan that outlines the help and support they require and this helps the staff to assist them. People can keep in touch with their family and when necessary staff will help them to do this. People who live at West Court Lodge said: It is a lovely place, nice people. And I enjoy living here. I would speak to Catherine or my key worker if I was not happy and I enjoy living here I can do what I want in the morning, evening and at the weekend. A relative said ‘They keep a good watch on the patients if they complain of any pain or medicine upsets and then if necessary get them to a doctor’ another said ‘Always keep me informed and have responded well if I have raised any concerns. Communication is good, staff are always patient and helpful when I visit.’ Information is available to people about outside support services and independence is promoted West Court Lodge DS0000007829.V335851.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. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. People who decide to use this service can be assured their individual needs will be assessed and recorded prior to entering the home. This means they know they will receive the support they require once in the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Admissions made to the home are done so in conjunction with an assessment provided by a placing agency. This assessment is supplement by a further assessment carried out by the manager. Four case files were seen and these contained both assessments. The assessment carried out by the manager is very much a working document and provides a holistic view of a person’s life and looks at their personal and daily life skills. People who live at West Court Lodge said that they were able to visit the home prior to their admission and that the manager had discussed their needs with them. The manager said that part of the assessment process was to look at the mix of people and their conditions before admitting anyone to the home. She aware of their limitations and responsibilities to people in the home. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. People are involved in decisions about their lives and are consulted about the care and support they receive. However, the care plans are not always followed through on a day-to-day basis. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All the people who live at West Court Lodge have a care plan. Four care plans were seen and these contained detailed information about mental health needs, personal care, social care, dietary needs, medication requirements and religious needs. The focus of the plans is about personal living skills and is about developing these skills. The plans are reviewed every six months and relevant health and social care professionals are invited to attend these reviews as are families. People spoken with were aware of their plans and said that they discussed them with their key worker regularly. The care plans identified areas of risk either through someone’s behaviour or physical West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 10 limitations and how staff should deal with the identified risks. A health professional said ‘they treat each resident as an individual and encourage care plans for individual activities’. Another professional expressed their concern that they did not always manage to speak to anyone who had a clear understanding of the care plans. One family member confirmed that a review is held regularly for their relative and whilst they are invited their relative does not want them present. Another relative said that they were always informed of reviews and of any changes to the care plans. People at West Court Lodge are encouraged to make decisions about their own lives with support primarily from the manager but also their key worker. During the visit people were seen approaching the manager for advice about a shopping trip and telling her where they would like to go for a holiday. Information about peoples’ finances and the support they required was detailed in their care plan. People were seen managing their own money and approaching the manager to save and pay bills. Whilst people are supported in making their own decisions staff should be aware of their need to maintain their personal hygiene at all times to ensure they do not become alienated from others in society. The care plans also require people to help clean and maintain their own bedrooms with support from their key workers. On a tour of the building it was clear this work was not being carried out. The manager felt that the standards had slipped as she had been away from the building for two weeks. During the visit it was also noted that personal activities were not always carried out, for example one person missed out on a walk because staff were busy elsewhere. (See staffing) West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. People have a varied programme of social activities that encourages them to develop personal skills and remain independent. The meals provide a balance between healthy eating and peoples’ preferences ensuring they have a balance and nutritious diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People in the home have a weekly plan of activities that they enjoy and these are aimed at helping maintain their general well being. These activities included, excursions to places of interest, shopping, quizzes, scrabble and going to local parks. Several of the planned activities are in conjunction with day services provided in Scarborough such as the local day centre and the local hospital for exercise regimes. Two people spoken with had recently enjoyed a holiday and someone else was discussing with the manager where West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 12 they would like to go for a break. People also have access to advocacy services if they require them. People are encouraged to keep their rooms clean and tidy as part of develop and maintain daily living skills. However several rooms were identified to the manager as being below an acceptable standard of cleanliness, having blocked sinks with dirty clothes for cleaning, dirty carpets and one room where the bed had been soiled and left. The manager explained that the key workers were responsible for assisting people with cleaning their rooms. People were seen during the day accessing all parts of the home and going out when they wanted. Several people said the could come and go as they wished the only thing they had to do was tell someone that they were going out and again when they returned. Family links are highlighted in a persons’ case file and feedback received from several relatives said that they were kept informed of what was happening in the home and specifically with their relative. Staff were observed waiting to be let in to a persons’ bedroom and observed their privacy at all times. Where staff have concerns about someone spending time on their own and becoming isolated this is documented and forms part of the care plan. The menus seen indicated that the meals provided are varied and nutritious. There is a mix of healthy meals with ‘fast food’ type meals all based on the likes and dislikes of people living in the home. There is a cook available for the afternoon and evening as the main meal of the day is eaten in the early evening. Staff prepare the breakfast and lunch meals and there is no set time for breakfast and lunch these are both relaxed meals, and not all the people who live at West Court Lodge eat there for these meals. Dietary needs are recorded and supplements are provided when necessary. Several people spoken with said that they enjoyed their meals and there was never any rush at mealtimes. Fresh fruit is available in the dining room at all times and people were seen helping themselves. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. Peoples’ health and personal care needs are met through regular monitoring by staff and input from health and social care professionals. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The people who live at West Court Lodge primarily require emotional and social support. There are several people who are starting to require help with their personal care, especially bathing due to the fact they are aging. The care plans reflect the level of support required and also show the involvement of health professionals as necessary. Feedback received from health professionals said that the home worked well with them especially if early interventions were required. They said that they had good working relationships with the manager. A family member also said that they were good at identifying health problems and getting the GP in. People spoken with said they could see their doctor when they needed to and any other health care professional they were involved with. Feedback received from a GP said ‘The home communicates clearly and works in partnership with health West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 14 professionals’. The manager and staff try to balance the rights of people with the responsibility of their caring role. However several people don’t like any involvement of staff and this leads to a poor standard of hygiene and this in turn leads to poor environmental standards. People were seen to be dressed in their own clothes and appropriately for their age. They usually buy their own clothes, sometime with support from staff or advocates and two people were seen planning a shopping trip with the manager. This allows them a sense of independence and they can make their own choices. A monitored dosage system is in place and the storage and administration of this medication was seen to be appropriate. People are encouraged to come to the office for their medication at all times and it is given in private. This system does mean that one member of staff can be tied up for long periods administering medication, leaving only one member of care staff working with people. Staff who administer medication have received training through a distance-learning course in the safe handling of medicines. A recent drugs error was reported to the Commission of Social Care Inspection and a risk assessment was seen to prevent this occurring again. There is a dedicated fridge for medicines and controlled drugs were stored appropriately. A record was seen of controlled drugs held and this was accurate. None of the people currently at West Court Lodge are assessed as being capable of managing their own medication. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. People living at this service are listened to and protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place at the home and it was displayed clearly in the dining room. People spoken with identified the manager or their key worker as someone they could speak to if they were unhappy or had any concerns. There was also information about the advocacy service and a MIND support group if anyone needed to speak to someone away from the home. Relatives spoken with also said they would feel confident in taking any concerns to the manager. There have been no complaints since the last visit. All of staff have had training in the safeguarding of vulnerable adults and those spoken with were aware of their responsibilities if they suspected any form of abuse occurring. There have been no allegations of abuse since the last visit. Staff have also received training in mental health, challenging behaviours and methods of restraint used in the home. No one has been subject to restraint since the last visit. A multi disciplinary adult protection policy is in place and staff were aware of this policy. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience adequate quality outcomes in this area. People live in a comfortable, safe environment however the overall appearance of the home is detracted by the exterior of the building and by the state of the carpets in communal areas and bedrooms that are not maintained to an acceptable standard of cleanliness. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: West Court Lodge is situation the south side of Scarborough and is a large building in keeping with the community around it. The paintwork on the exterior of the building is peeling and provides visitors with a poor first impression of the home. This was identified at the last inspection carried out on the 10th August 2006. The manager has identified this with Care UK Mental Health Partnership, the company that owns this building and she has been informed there are no monies available at this time to carry out the work. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 17 There is a CCVT camera located at the front entrance for safety reasons. The monitor is situated on the lower ground floor and allows staff to monitor people entering and leaving the building. The communal areas of the home were reasonably clean and in the lounge there was new suite for people to use. The carpets in all communal areas were dirty and badly stained. The manager said that they had been advised to stop washing the carpet because the flooring underneath was disintegrating. All of the bedrooms were seen and the majority of them were decorated to high standard and contained furniture and personal items as wanted by the occupant. Several rooms were pointed out to the manager as being dirty and having stained carpets. It was clear that the cleaning regimes as described in people’s care plans were not being followed. The manger did say that the occupants of these rooms were not highly motivated to keep them clean, or did not want anyone in touching their personal items. However, the manager and staff have a duty of care and should not let these rooms fall below the accepted minimum as it becomes degrading for the occupants by default. Again these issues were raised at the inspection carried out 10th August 2006. During the visit there was only one domestic member of staff on duty and she was also involved in providing support to the people in the home. There did not seem enough domestic time to allow for the building to be kept acceptably clean. A maintenance plan was seen and small works are completed quickly whilst others are carried out when funding is available. There is no passenger lift in the building and so ambulant people can only access it. This is reflected in the Statement of Purpose. A separate outside area has been created for people who smoke. Smoking is currently allowed in the main lounge, this will have to cease following 1st July 2007. People are not encourage to smoke in their rooms but where this happens the furnishing supplied have been fire retardant and risk assessments are in place. The laundry is appropriate for the needs of the people who live at West Court Lodge and those who can are encouraged to do their own laundry with support. People spoken with liked living at West Court Lodge and said they were happy with their own rooms. One person admitted they didn’t like doing domestic tasks and this was reflected in the state of their own room. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. The level of day staffing limited the amount of quality time that staff could spend with people on a one-to-one basis thereby undermining the quality of the service provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During the visit there were two support workers on duty and one domestic staff member available to the people who live at West Court Lodge. One member of staff was responsible for dispensing the medication whilst the other was responsible for getting breakfast for the people who came down to the dinning room. One of the support workers had only been in post for fourweeks and was working on their own with little guidance from anyone else and at times they seemed lost as to what they could be doing. There are fourteen people who live at West Court Lodge and whilst one staff member is administering the medication this leaves a ratio of one to fourteen. Where people have personalised care programmes that indicate individual activities West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 19 with support there is not the staff nor the time to carry these out effectively rendering care plans no more than a paper exercise. The member of staff carrying out domestic tasks spent time escorting someone out in to town, and assisting with personal care with a support worker, this means that there was not enough time for them to spend on general domestic duties. The gender mix of support staff would not allow people at West Court Lodge to make a positive choice about who assists them with their personal care. Whilst the manager was describing a supportive residential environment the reality is that because of the lack of staff to assist people on a one-to-one basis West Court Lodge operates more like a hostel. Staff operate the key worker system and whilst they try to provide female staff to assist women who live in the home it is not always possible and they may have a male member of staff as a key worker. The key workers are responsible for assisting people with their independent living skills. This includes encouraging them to keep their rooms clean and tidy. Evidence seen during the visit showed that this approach did not seem to be working and the manager needs to look at this issue as part of the process of improvement within the home. People spoken with said that they liked the staff and all of them knew their key worker. The staff records seen contained evidence of a thorough recruitment procedure and all records contained evidence of Criminal Records Bureau disclosures. One member of staff spoken with said that in their first four weeks they had received moving and handling training and fire training. The manager has also run through the basic induction process with them. Evidence in the staff files showed they had been provided with training to assist with their roles and cover topics such as; mental health, moving and handling, abuse, break-away training, infection control. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. The people and staff at West Court Lodge are provided with good standards of management support. This support is aimed at ensuring the service meets the stated aims of the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Registered Manager operates an open door policy with people who live at West Court Lodge, staff, visitors and visiting professionals. She was seen engaging in conversations with people who came in and out of the office at will. People spoken with thought the manager was friendly and that she would take any concerns seriously. She has implemented staff supervision. The deputy manager carries this out. She works well with visiting professionals West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 21 and visitors spoken with during the visit expressed confidence in what she had achieved since starting and in the day-to-day running of the home. Care UK have introduced a quality improvement plan and an annual audit is carried out covering the home, staff and manager are every year and the results form an improvement plan. Information is also taken from the staff meetings and general house meetings for the people who live at West Court Lodge. In-house activities are also planned through these forums. All the appliances had recent safety certificates and staff have had training in all aspect of health and safety in the workplace. Where necessary risk assessments are in place for the environment, and for people who live at West Court Lodge. All incidents and accidents are recorded and when necessary reported to the Commission of Social Care Inspection. West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 3 X X 3 X West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 23 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 YA30 Regulation 23 Requirement The carpets in the identified bedrooms and stairways must be cleaned or replaced. The décor and furnishings in the identified bedrooms must be clean and hygienic. The previous timescale of 01/11/06 has not been met The level of the day staffing must be reviewed and if necessary revised to ensure that it is adequate to meet all of the assessed needs of the service users. The previous timescale of 01/11/06 has not been met. Timescale for action 31/07/07 2. YA33 18 31/07/07 West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 24 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 YA6 Good Practice Recommendations Staff should be aware of individual care plans and ensure they are carried out. They should also be able to discuss care plans with other professionals. Care UK should make plans to ensure the maintenance of the building is kept up to date. Newly appointed staff should receive regular training and support until their induction is completed. 2 3 YA24 YA34 West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 West Court Lodge DS0000007829.V335851.R01.S.doc Version 5.2 Page 26 - 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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