Inspection on 26/11/07 for West House Residential Home

This inspection was carried out on 26th November 2007.

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

West House Residential Home 25/11/08

West House Residential Home 09/10/06

West House Residential Home 02/02/06

West House Residential Home 28/09/05

West House Residential Home 06/12/04

West House Residential Home 06/09/04

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

CARE HOMES FOR OLDER PEOPLE West House Residential Home 14-16 Quarry Road Westtown Dewsbury West Yorkshire WF13 2RZ Lead Inspector Tracey South Key Unannounced Inspection 26 November 2007 09:15 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 West House Residential Home DS0000045064.V352008.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. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West House Residential Home Address 14-16 Quarry Road Westtown Dewsbury West Yorkshire WF13 2RZ 01924 469416 01924 437084 northfields@leedscare.co.uk 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) Northfields Care Homes Ltd Rodney Turner Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th October 2006 Brief Description of the Service: West House is a home for thirty-seven people with dementia care needs. home is owned and managed by Northfields Care Homes Ltd. The The home is situated approximately one mile from Dewsbury town centre close to the main Huddersfield Road, and consists of a large Victorian house that has been extended twice in recent years. There are pleasant gardens to the front of the house. The Commission for Social Care Inspection was informed that as at 26.11.07 the fees ranged from £335.24 to £358.80 per week. Additional charges are made for hairdressing, chiropody, personal toiletries, magazines, etc. Information about the home in the form of a Statement of Purpose, Service User’s Guide and the latest Commission for Social Care Inspection report are available from the home. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out to the home by the inspector on the 26th November 2007. The visit began at 09.15am and the inspector had left the home by 4.10pm. During the visit the inspector spoke with some of the people who live at the home, care staff, the home’s acting manager, the organisation’s estate manager and two visiting relatives. Care records were examined and the inspector audited a sample of medications, reviewed staff recruitment records, and looked around the home. The acting manager also completed an annual quality assurance assessment that was requested by CSCI (Commission for Social Care Inspection) about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. Prior to this visit surveys were sent out to obtain the views of people who live at the home, their relatives and people’s doctors. Eleven surveys were sent out to people living at the home, two were returned. The reason for this could be attributed to people’s frailty. Eleven surveys were sent out to relatives, seven were returned. Surveys were also sent to people’s doctors two of which were returned. Ten staff surveys were sent out to the home for completion, two were returned. There were 30 people living at the home on the day of this visit. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 6 What the service does well: Relative’s surveys asked, “What do you feel the care home does well?” Responses include: “Keeps the residents clean and well fed. Staff spend time chatting to them when they have time. Organise social events.” “The staff seem very caring towards the residents. The meals are very good. The home always appears clean and warm.” “My mother is always loved and cared for to the best of their ability. She is well fed and always nice and clean.” “Care well, they have time and patience.” Although people were not able to comment directly about their life at the home it was clear from observing care practice throughout the day that people are well cared for. People visiting West House during the inspectors visit gave positive feedback about the home. They spoke highly about staff saying they are friendly, caring and approachable. One visitor said she would have no hesitation whatsoever in speaking to someone if she was unhappy about something. The manager encourages people to visit the home along with their relatives before making their mind up as to whether it’s the right home for them. Being able to visit gives people an insight into what West House has to offer them. People at the home receive a well balanced diet and are offered two choices at lunchtime. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Comments received by staff on how things could improve include, “More one to one with residents, perhaps volunteers to help at times.” Relatives were asked for their comments on how the care home can improve. The CSCI received the following comments: “I think it has.” “More staff. As always, seems to be short staffed when I visit but I do visit on a Saturday.” “I understand how difficult it must be dressing older people but it would be nice to see my relative wearing her own clothes. She has plenty.” “Employ more staff. Do more with residents through the day. Make use of the visitors book, its never about.” “Sometimes there isn’t enough staff to cope.” More emphasis must be made on ensuring that each person’s care plan clearly outlines their needs and the care and support they require from staff. Daily reports should include information about how the person has spent their day including whether their care needs have been met. The organisation should ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved. Qualified staff will have a better understanding of the needs of people in their care. All staff must receive training in order for them to carry out their jobs, this includes safeguarding (adult protection), health and safety, food hygiene, infection control and dementia care training. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 8 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 House Residential Home DS0000045064.V352008.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 West House Residential Home DS0000045064.V352008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: West House offers care and accommodation for up to 37 people with dementia care needs. The acting manager is responsible for carrying out pre-admission assessments on people who have been assessed as needing this type of care. The purpose of this assessment is not only to establish the person’s needs but also to enable the manager to ascertain whether or not West House is able to meet that person’s expectations. There was good evidence in the three people’s care records examined that they had been properly assessed before moving into the home. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 11 The manager explained that she encourages people to visit the home prior to them moving in. This gives them the opportunity to have a look around the home, speak to other people who live there and meet the care staff. One relative who spoke with the inspector said when she came to look around the home she was impressed with how friendly the staff were towards her and her family. There was mixed views from relatives about whether they receive enough information to help them make decisions. The majority felt they usually did as opposed to always and one relative said, “My understanding is that there is a new manager at West House, but I have not been informed-or introduced-we don’t even know her name.” Comments of this nature should be addressed by the organisation to ensure people living at the home and their relatives are kept up to date with information about the care home. West House Residential Home DS0000045064.V352008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. In order to give the exact care and support people need, care plans need to improve. People are protected by the home’s medication system and their rights to privacy and dignity are supported by caring staff. EVIDENCE: The care records of three people were examined. These people had moved into the home within the last four months. The care plans had been written by the acting manager who had used information from the pre-admission process including information supplied by the social work team and health care trust. The care plans describe people’s needs but not in every case do they describe the level of support the person requires to ensure their needs will be met. For example, one care plan talked about maintaining independence but not how this would be achieved. Another example was the need to promote a healthy West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 13 diet but the care plan didn’t include anything about what this person likes to eat or drink. Care plans need to be improved to ensure that people receive the right level of care. There is very little written in people’s care plans that refer to their religious and social care needs. In one person’s pre-admission assessment it stated that at their previous home they regularly received Communion from the priest and enjoyed playing bingo. Neither is mentioned in the person’s care plan and therefore no evidence that these needs are being met. There was no evidence in place to suggest that people are involved in the care planning process. This was highlighted as an area of development for the home during the last inspection in October 2006. Without the input from the individual and/or their relative it is difficult to develop a plan using a person centred approach that focuses on the person as an individual. Daily reports should give the reader a snap shot of how each person has spent their day and highlight any issues of concern. The daily reports examined did not always provide this level of detail. Some reports were opinionated; one person was described as being “argumentative”. Staff should refrain from writing judgemental statements about people and focus more on describing how their needs have been met. There were some good examples of wellwritten reports and the manager should use this as a training opportunity for those staff that perhaps find this task difficult. Care records include risk assessments that have been carried out to identify any risks to the individual, for example, when a person is at risk of falling. Where a risk has been identified a care plan is produced to minimise the risk. Plans used to identify the support people require with their mobility describe the assistance required so staff are clear about what is expected from them and people are helped in a safe manner. There was good evidence in people’s care records that they are able to access health care services, such as the dentist, chiropodist, optician and everyone living at the home is registered with a doctor. Surveys returned by GP’s indicate that they share a good relationship with the staff at West House and that they are satisfied with the overall care provided to people living there. Surveys completed by people living at West House confirmed that they receive the medical support they require. A visitor told the inspector that the staff are very good at following up when her relative isn’t very well. She explained how staff had involved the GP from an early stage and how they kept an eye on things until they had improved. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 14 A sample of three people’s medication was checked during the visit. This showed there to be good systems in place for the recording, storing, administration and disposal of medications. The medication record sheets were neat, tidy and easy to follow. The manager was advised to separate the medication keys from any other keys used in the home to eliminate the possibility of abuse. West House Residential Home DS0000045064.V352008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure people’s social, cultural and religious needs are identified so that the appropriate support can be given that meets people’s expectations. EVIDENCE: There has been very little in the way of daily activities since the activities coordinator left in September 2007. The manager explained that there has been the occasional entertainer who has visited the home. And every fortnight a therapist visits to carry out gentle exercises with people. The manager said that she has appointed a new activities co-ordinator and is currently waiting for employment checks to be carried out on this person. There was very little happening in terms of staff engaging with people during this visit. On occasions some staff did interact well with people but there was a large number of people who where sat with nothing to do or no one to talk to. This was reinforced by comments received from relative surveys, that is, “Residents seem to spend a great deal of the day just sat in the lounge. There is very little interaction going on or stimulation from my observations.” West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 16 It is important to establish what people would like to do in terms of their interests, once this has been identified activities can be tailored to suit individual needs. Relatives are welcome to visit the home at any reasonable time. The inspector spoke with two visitors, both were complimentary about the home. They both said that the staff are very friendly and approachable. They both agreed that redecoration of the home has made a difference in terms of looking cleaner, brighter and more homely. Surveys sent to relatives asked, “Does the care home support people to live the life they choose?” Most people replied, ‘always’ and ‘usually’. Others felt it was a difficult question to answer because of the level of people’s dementia in terms of understanding what they really wanted from life. When observing care practice it was clear that some people were restricted in what they were allowed to do. Some people were asked to go sit back down and one person was escorted back to another part of the lounge and told she would be more comfortable there even though she looked happy where she was. The manager needs to ensure that people living at the home are able to exercise their right to make their own choices and this includes walking around the home freely. Staff were observed serving lunches to people which looked appealing and people seemed to enjoy their meal. The manager was advised to ensure that staff who offer assistance to people with their meals sit at the side of them rather than kneeling on the floor. This practice is not advisable in terms of health and safety and is not very discreet. Table settings were sparse and there was no evidence of any condiments or napkins on offer and this should be addressed. People who completed surveys said that they usually like the meals at the home. West House Residential Home DS0000045064.V352008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints will be listened to and acted upon. Not all staff are trained on how to deal with safeguarding matters which could put people at risk from abuse. EVIDENCE: The home’s complaints procedure is located in the front entrance of the building although the details about the CSCI’s local office are not up to date. The manager said she would make sure the details are updated. Most relatives said they know how to make a complaint and knew who they would go to if they were concerned about something. The home has received one complaint in the last 12 months. The complaint was dealt with appropriately and the complainant was informed of the outcome of the manager’s investigation within the agreed timescale. When examining the staff training matrix it appears that fifteen people have not received safeguarding (adult protection) training. Since speaking to the Manager after the visit she feels that this information is incorrect and those West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 18 fifteen people are due refresher training as the company provided safeguarding training on a yearly basis. Whatever the case in order to protect vulnerable people against abuse all staff must receive up to date training to ensure they know how to respond should there be any allegations of abuse in the home. West House Residential Home DS0000045064.V352008.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers people a homely, comfortable and clean environment. EVIDENCE: Excellent progress has been made in terms of upgrading the home. Major refurbishments have been ongoing and rooms have been redecorated and recarpeted and furniture has been replaced. A number of newly decorated rooms were seen during a tour of the home and the standard of décor is very good. Communal areas have been fitted with new carpets and new easy chairs have been purchased. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 20 Non-slip flooring has been fitted in the ground floor dining room and some of the corridor areas. All bathrooms and toilets on the ground floor have been redecorated and one of the bathrooms on the first floor has been re-designed as a shower room. Redecoration of the first floor accommodation is now taking place. The standard of cleanliness in the home is good and there were no unpleasant odours noted in any part of the home. The atmosphere on the day of the visit was warm and friendly and people looked comfortable whilst sitting in various parts of the home. The manager acknowledges that refurbishment needs to continue to bring all rooms up to a good standard. It is commendable the amount of work which has taken place within the last six months in providing better outcomes for people living at West House in terms of the environment. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by staff who have undergone a thorough recruitment process before they are allowed to work in the home. Not all staff have received the training required to enable them to do their job competently. EVIDENCE: The duty rota confirmed there to be four/five care staff on duty during the day and three care staff work during the night. Care staff are supported by domestic, laundry and kitchen staff. The manager’s hours are supernumerary. When asked if the care staff have the right skills and experience to look after people properly, the majority of relatives feel that they do. Visitors spoken with on the day of the visit were complimentary about the staff at West House saying they are friendly, caring and approachable. There is 48 of the care staff who have achieved an NVQ (National Vocational Qualification) level 2 in care. The organisation must continue in working towards achieving at least 50 of the workforce with this qualification. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 22 The recruitment files of three members of staff were audited in detail and found to contain the required information and employment checks. These checks are necessary to help protect people from potentially unsuitable staff. The manager was advised to ensure that all staff files contain a recent photograph of the person as proof of identification. New staff undertake induction training in accordance with Skills for Care, the National Training Organisation for care staff. However, the inspector was concerned that the records relating to two new staff were signed off as them having completed the training in one day. Guidance from the National Training Organisation states that the new staff are expected to complete the standards within their first twelve weeks of employment. This questions the validity of the induction records examined during this visit and the organisation need to address such an approach to inducting new staff. The staff training matrix indicates that some staff have received training at some point during their employment at the home. However there are a number of gaps in the training undertaken. For example, eighteen staff have been identified as not having had food hygiene training, ten staff have not completed infection control training, eight staff have not completed health and safety refresher training for over two years and four staff have no record of completing any health and safety training at all. Very few staff have completed dementia training despite West House providing care to people with dementia needs. The manager said that it was her understanding that the majority of staff had received some form of dementia training but she could not confirm this. The CSCI require evidence that such training has taken place and if not arrangements must be made for all training as previously mentioned to take place within the next four months. Two staff who completed surveys said they felt that they received training relevant to their role and that they are kept up to date with new ways of working. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, safety and welfare of people living at the home and staff is promoted and protected. EVIDENCE: Ms Linda Blackburn is the acting manager at West House. She has been in post since September 2007 and has a number of years experience of working with older people in both residential and nursing homes. Ms Blackburn has a NVQ level 4 in Care and recently completed a four day manual handling training course which will enable to train care staff in movement and handling techniques. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 24 Staff gave positive feedback about the manager saying she is approachable and supportive. Relatives were also complimentary about the manager saying although they had not had a lot of dealings with her she did appear to be kind and approachable. Ms Blackburn comes across as a caring individual with a genuine desire to look after people and provide good quality care. There is a quality assurance system that seeks the views of people who live at the home, their relatives and visiting professionals such as the district nurse and GP’s. Satisfaction questionnaires are sent out to people each year and as this quality system is in its first year it was not possible to look at any published reports. The organisation needs to ensure that it shares the findings of satisfaction questionnaires with all interested parties. Some people have small amounts of personal money that is held safely at the home. Records are available to show when money is deposited on behalf of people. The records show the individual cash balance for each person and how their money is used on their behalf, including receipts for goods and items purchased. Three people’s finances were checked during the visit and were found to be correct. The manager was reminded to make a receipt of any personal items, such as jewellery that are being held on behalf of people. The home’s quality assurance assessment indicates that routine maintenance and servicing of equipment takes place. The manager has recently reviewed fire safety checks when she highlighted a number of concerns. As a result the home is now carrying out weekly fire safety checks and these are recorded. Following a recent fire drill the manager felt it necessary for all staff to receive refresher fire training and explained that by 29th November 2007 all staff will have completed this training. West House Residential Home DS0000045064.V352008.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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 3 West House Residential Home DS0000045064.V352008.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 OP7 Regulation Requirement Each person’s care plan must clearly outline the level of support they require, as this will ensure that they receive the right level of care. 15 Care plans must reflect the residents social care needs as well as health and personal care. Requirement repeated timescale of 30.10.06 not met. 17(1)(a) Each case file must contain a photograph of the resident as stated in the regulations. Requirement repeated timescale of 30.11.06 not met. Confirmation is required to show that all staff have received safeguarding training in accordance with the home’s procedures. Otherwise staff must receive this training in the next three months. All staff must receive training in order for them to carry out their jobs. (Requirement brought forward as timescale of 28.2.06 not met). DS0000045064.V352008.R01.S.doc Timescale for action 30/12/07 2 OP18 13 28/02/08 3 OP18 18 30/12/07 West House Residential Home Version 5.2 Page 27 Confirmation of training undertaken must be sent to the CSCI by 30/12/07. All staff must be suitably trained within the next four months. 4 OP30 18 All new staff must receive induction training in line with Skills for Care Common Induction standards within their first three months of employment. (Requirement brought forward as timescale of 28.2.06 and 30.10.06 not met). 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP12 OP14 OP15 Good Practice Recommendations People living at the home and or their relatives should be encouraged to participate in the care planning process. More emphasis is required in establishing people’s social, cultural and religious needs so a plan can be developed that meets their expectations. People should be given the freedom to make their own choices about how they spend their time and this includes walking around the home freely. Staff should ensure that people receive help and support with their meals in a sensitive and discreet manner. Condiments and napkins should be made available to people at mealtimes. Work should continue to upgrade the environment on the first floor accommodation. The organisation should continue working towards 50 of the care team having a NVQ qualification. An application should be submitted to the CSCI for Ms DS0000045064.V352008.R01.S.doc Version 5.2 Page 28 5. 6 7 OP19 OP28 OP31 West House Residential Home Blackburn to become the registered manager of West House. West House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 House Residential Home DS0000045064.V352008.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!