Inspection on 01/03/05 for West House Care Home

Care Home For Older PeopleWest House Care HomeWaldridge Road Chester Le Street Durham DH2 3AAUnannounced Inspection1st March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment West House Care Home Address Waldridge Road, Chester Le Street, Durham, DH2 3AA Email address Name of registered provider(s)/company (if applicable) Roundview Properties Ltd Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 30 Tel No: 0191 387 1533 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (30), Terminally ill (3) Registration number B540002051 Date first registered 31st December 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 31st December 2004 YES NO 28/09/04 If Yes refer to Part CWest House Care HomePage 1 Date of inspection visit - Unnanounced Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 31st March 2005 09:15am Mrs Tanya NewtonID Code073272Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionWest House Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWest House Care HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of West House Care Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.West House Care HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. West House is a home owned by Roundview properties Ltd. It is registered to provide care for up to 30 older persons who may require nursing or residential care. The home offers single and double room accommodation with communal sitting/dining areas. West House is situated in Chester-le street, a town near to Durham and Newcastle.West House Care HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection of West House was carried out on the 1st March 2005. The inspection was general in nature and focused on the following national minimum standards: 1 ­ 5, 7, 8, 10 ­ 12, 14 ­ 19, 26 ­ 28, 30, 31, 33, and 35 ­ 38. The home has recently been sold and is under new ownership. Service users and relatives were spoken to during the inspection to gain feedback on the standard and quality of care being provided by the home. Ten service users comment cards were received following the inspection, six were very positive in nature, four raised concerns regarding the numbers of staff on duty. Eight service users comment cards were also received, the comments again in the main were positive, one stated that there should be more opportunities to go out on activities, three only liked the food some of the time. Any standards not inspected during this inspection will be scored as 0 and will be addressed in future inspections of the home. The following is a general summary of the findings within the inspection report: Choice of Home (Standards 1 ­ 6) All 6 standards were assessed, 4 met the standard,1 almost met the standard and 1 area was not applicable. The statement of purpose, statement of terms and conditions and service users guide to the home has been recently updated. Health and Personal Care (Standards 7 ­ 11) 4 standards were assessed, 3 met the standard, and 1 almost met the standard. Service users care plans have been updated and there were significant improvements in this area since the last inspection of the home. Privacy and dignity is maintained and service users confirmed this during the inspection. Daily life and Social Activities (Standards 12 ­ 15) 3 standards were assessed; they all almost met the standard required. Activities are under review and work has been carried out to conduct a social assessment on each service user, service users would like more opportunities to go out. Visitors confirmed that they were made welcome. Complaints and Protection (Standards 16 ­ 18) All 3 standards were assessed, 2 met the standard and 1 almost met the standard. The adult protection policy requires updating; the complaints policy should be available in more user accessible formats.West House Care HomePage 6 Environment (Standards 19 ­ 26) 2 of the 8 standards were assessed; both were almost met. Plans have recently been submitted to CSCI to improve and extend the environment, if building approval is granted works will be undertaken, followed by a programme of redecoration. Staffing (standards 27 ­ 30) 3 standards were assessed; 1 was met, 1 was almost met and 1 was not met. Comments from service users staff and relatives regarding the staffing levels were mixed; the home should keep this under review. The home need to monitor the number of staff attaining NVQ qualifications, the induction pack provided by the home has been recently updated. Management and Administration (standards 31 ­ 38) 6 standards were assessed; 2 met the standard and 4 almost met the standard. There is no registered manager, however the home are taking action to address this. Quality audit tools to seek feedback from service users and/or their relatives are being developed. Fire training records must be held.West House Care HomePage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 15 OP7 As highlighted in the previous inspection report Service users must continue to be given the opportunity to be involved in their care plans As highlighted in the previous inspection report The registered person must conduct the home to maximise service users right to autonomy and choice, service users should be actively involved in the running of the home. Where service users are given keys to their rooms, risk assessments should be carried out. 3 16 m & n OP12 Activities arranged by the care home must be based on service users feedback, which was gained during the social assessment. The adult protection policy requires minor review, and staff should receive training in this area. Records of all fire drills must be maintained. 30th April 2005. 30th April 2005. 30th April 2005. 30th April 2005.212(2)OP1430th April 2005.413(6) 23(4) c d and eOP185OP38West House Care HomePage 8 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 2 OP27 OP26OP4 OP28 OP30OP2 9 OP36 OP19 A review of the current staffing arrangements should be carried out. The number of staff having gained an NVQ 2 or equivalent should be monitored. Training which relates to the specific needs of the service users accommodated should be provided and should include infection control. Recruitment practice should include volunteers; staff should receive a copy of The General Social Care Council (GSCC) code of conduct. Supervision should be provided at least 6 times per year for all staff. A programme of redecoration should be considered throughout the home.34 5 6* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.West House Care HomePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO YES NO YES NO YES YES YES YES YES YES NO YES 6 6 0 NO NO YES YES 15 8 01/03/05 09.15 5.5West House Care HomePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.West House Care HomePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? The standard is met: There is a recently updated statement of purpose and service users guide to the home, both documents should be made available in more user accessible formats such as large print or audio. The service users guides in bedrooms are the old versions and should be updated.West House Care HomePage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The standard is met: There is a recently updated statement of terms and conditions, which contains all of the required information. This is provided on admission to the home and is signed by the service user or relative where the service user is not able.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The standard is met: Assessments were viewed during the inspection; they included all of the relevant information. Assessments form the basis from which the care plan is written.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The standard is almost met: Assessments are in place and form the basis of the care plan which demonstrates how the home will meet the individual needs of the service user placed within West House. Training for care staff, which relates to the specific medical conditions of the service users placed should also be provided.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The standard is met: Information relating to admission is included within the statement of purpose; it states that all service users are encouraged to visit the home prior to admission.West House Care HomePage 13 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard was not applicable.West House Care HomePage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The standard is met: There have been positive improvements to the standard and quality of care plans within West House. The care plans viewed were well documented and contained specific information detailing the individual requirements of the service user. Care plans are being reviewed regularly. A photograph of the service user should be held on their individual case file, and evidence of service users input within the plan of care should be maintained. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 4 33 Key findings/Evidence Standard met? The standard is met: Review of documentation and discussion with service users and their relatives demonstrate that the home is meeting this standard. Access to other professionals is sought where it is required.West House Care HomePage 15 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was not formally assessed: The home has decided to discontinue using the monitored dosage system, due to lack of storage space. Medication was assessed during the last inspection of the home.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The standard is met: Service users confirmed that staff spoke them in a polite manner and knocked on doors prior to entering. Relatives confirmed that service users were treated in a dignified manner.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 2 Key findings/Evidence Standard met? The standard is almost met: The home has started to seek the views and wishes of service users and their relatives in this sensitive area, where this information has been gained it is included within the individual care plan.West House Care HomePage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The standard is almost met: Social assessments have been completed for all of the service users living within West House, and there is an activity co-ordinator employed by the home. Feedback from service users and relatives was poor with regard to the social activities being offered; however work is ongoing in this area.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 2 Key findings/Evidence Standard met? The standard is almost met: Locks have been provided to all rooms, service users are to be asked if they want to hold a key to their room, and risk assessments carried out where required. Service users confirmed that they could personalise their bedroom with personal possessions and furnishings. Service users should be consulted with regard to general decision-making regarding the home.West House Care HomePage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The standard is almost met: The previous cook has left since the last inspection of West House, and a replacement has been found. Comments regarding the standard and quality of food being provided were in the main positive. The management at West House confirmed that menus would be reviewed and that feedback would be sought from service users in this area.West House Care HomePage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? The standard is met: There is a complaints procedure available which includes the contact details for the Commission for Social Care Inspection; it would be beneficial for the home to provide this procedure in more service user accessible formats.West House Care HomePage 19 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The standard is met: information regarding service users legal rights is included within the homes statement of purpose. Service users would be supported within the electoral process if they wished.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 02 Key findings/Evidence Standard met? The standard is almost met: The adult protection procedure would benefit from further expansion to reflect the lead role of social care and health in adult protection issues. The restraint policy requires review as it makes reference to restraint yet the home confirmed that restraint does not take place. The service users financial procedure requires review and should reflect the maximum limit of money to be held. Audits should be carried out on finances. The staff would benefit from training in adult protection.West House Care HomePage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The standard is almost met: Plans have been submitted to CSCI to extend and improve the environment at West House, the home are currently waiting for building approval in order that works can commence. A programme of redecoration will follow any building works, as there have been a number of previous comments regarding the dark décor.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed, however see comments under standard 19.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed, however see comments under standard 19.West House Care HomePage 21 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed, however see comments under standard 19.West House Care HomePage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES X X X X 0 X XX X X XKey findings/Evidence Standard met? This standard was not assessed; however see comments under standard 19.West House Care HomePage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed, however see comments under standard 19.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not assessed; however see comments under standard 19.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The standard is almost met: There were some odours present in some areas of the home, this should be addressed and staff would benefit from training in infection control.West House Care HomePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X8 15 72 Key findings/Evidence Standard met? The standard is almost met: The home is staffed in the following way, 5 carers work the early shift, 4 work the afternoon shift, 3 work the evening shift and 2 work during the night. There is a qualified nurse working at all times. Comments from relatives and service users were mixed regarding the numbers of staff on duty. This should be reviewed.West House Care HomePage 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X 20 1 Key findings/Evidence Standard met? The standard is not met: At present only 20 of staff working within West House have an NVQ qualification (or its equivalent). Seven staff were due to commence NVQ training following the last inspection in September, however none have begun this. In order that the home can meet the standard required 50 of staff should have achieved NVQ level 2 of its equivalent by 2005. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The standard is met: An induction, which meets NTO and TOPSS specifications, has been implemented. This will be provided for all new staff that commence employment within West House.West House Care HomePage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The standard is almost met: There is no registered manager in place within West House; however the home is taking action to address this.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? The standard is almost met: Regulation 26 visits are carried out, a quality audit tool has been developed which will seek the views of service users and relatives regarding the standard and quality of care being provided within West House. This is expected to commence in April 2005.West House Care HomePage 27 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? The standard is met: The home does not act as an agent for any service user; relatives take over this role where service users are not able. Records of income and expenditure relating to service users personal monies are maintained although these were not inspected on this occasion.Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? The standard is almost met: Supervision for staff has commenced this should continue in order that all staff receive a minimum of six supervision sessions over the year, training for staff should continue to be developed particularly within adult protection and NVQ.West House Care HomePage 28 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? The standard is met: There has been an improvement within record keeping within the home, the standard of recorded information has improved and records inspected were generally well maintained.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The standard is almost met: Although staff testimony confirmed that fire drills were being carried out, which included practical tasks such as a smoke filled room, there were no records being maintained. The home must ensure that records of all fire drills and evacuations are maintained.West House Care HomePage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorTanya NewtonSignature Signature SignatureRegulation Manager Michele Hargan Date 22nd March 2005Public reports It should be noted that all CSCI inspection reports are public documents.West House Care HomePage 30 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 1st March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWe are working on the best way to include provider responses in the published report. In the meantime responses received are available on request from Darlington Area Office.West House Care HomePage 31 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 19th April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here West House Care HomePage 32 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Mr R B C Owen of West House confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.West House Care HomePage 33 West House Care Home / 1st March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000062946.V213994.R01© This report may only be used in its entirety. 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