Inspection on 22/08/06 for West Lodge

This inspection was carried out on 22nd August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Lodge 24/07/08

West Lodge 25/07/07

West Lodge 17/10/05

West Lodge 24/05/05

West Lodge 24/11/04

West Lodge 30/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 West Lodge 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 22nd August 2006 10:00 West Lodge DS0000015758.V304224.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 Lodge DS0000015758.V304224.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 Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Lodge Address 39 Frederick Gardens Penshaw Houghton-le-spring Tyne And Wear DH4 7JY 0191 385 7169 0191 385 7169 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) www.c-i-c.co.uk. Community Integrated Care Ms Yvonne Marie Reay Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (3), Mental disorder, excluding of places learning disability or dementia (1), Physical disability (2) West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: West Lodge is a detached two-storey building, which was originally a private house. It is situated in a quiet location at the end of a cul de sac amongst a variety of private houses in Penshaw. Some structural alterations were undertaken prior to the homes registration but it retains its domestic appearance in many ways. There is a spacious drive sufficient to park four vehicles and local amenities such as a post office, corner shops, and pubs within a few minutes walking distance in Penshaw. The building provides six individual bedrooms, two of which are on the ground floor and four on the first. There is a large lounge/dining room, kitchen and laundry room all shared by the service users as well as accessible well stocked gardens. The home is registered to offer a service to 6 people with a learning disability, including 2 who may have physical disabilities and 2 over the age of 65years and 1 with additional mental health needs, this is for a specifically named person. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met. A copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £879.05p per week. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Questionnaires were sent out to service users’ relatives prior to the inspection and four were returned. Three relatives indicated that they were satisfied with the service delivered, one complimenting the performance of the new manager, another relative demonstrated that they were dissatisfied with the standard of care. The particular issues that one relative was dissatisfied with were discussed with the manager and case tracked in the care records as part of the inspection process. The views of the six service users and five members of staff were sought. As three of the service users do not have effective verbal communication their satisfaction of the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. A service user who had recently moved into the home and who is able to verbally communicate was able to give an explicit account of their introduction to the home, this was positive. As part of the inspection process the service users’ care files and a sample of the homes records were examined and an inspection of the premises took place. What the service does well: Information about the service at West Lodge is written in a book called the Service User Guide. This clearly gives information about the service and has good photographs of different parts of the building so that people can see what it is like inside. People are also invited to look around the house before deciding to move in. This helps people to make a decision about where to live. A service user who had recently moved into the home said that they were happy with their choice of home, they liked the people they were living with and they were “well looked after”. It is very comfortable inside West Lodge, there is good furniture and the rooms are nicely decorated. It is well looked after and kept very clean and tidy. Some of the staff have worked at West Lodge for many years and know the service users very well. All of the staff are taught how to support and care for people with learning disabilities. This means that service users receive the right kind of support. The friendliness shown between guests and staff makes everyone going into West Lodge feel very welcome. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 6 Staff support service users to try different activities in the home and in the local community. So that staff know how service users like to be supported with things that they cannot do themselves, service users and their families help staff to write down instructions for staff to follow. These are called care plans. Each service user has a care plan that has pictures and photographs to make it easier to understand what has been written about them. If a service user takes part in an activity that might present a risk the staff are given directions how to keep the person safe. Service users receive a good variety of food that is served to them in a way that they can manage and prefer. What has improved since the last inspection? What they could do better: There should be more information included in the service users’ contracts so that service users know and can agree how the money they are receiving and paying out is being used. So that the house is kept safe and in good repair, anything that is broken or needing to be decorated, must be done promptly. So that service users know the staff well who support them with personal tasks and out on activities, the manager must make sure that any staff vacancies are filled as soon as possible. This will mean that staff, who service users do not know very well, from outside the home will be used less. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 7 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. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 8 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 Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective service users are provided with information about the home and are invited to look around before making a decision to move in. This helps service users to make an informed choice about where to live. The needs of prospective service users are appropriately assessed prior to moving in and as a result the service is able to confirm to the service users whether they can meet their needs. The home provides all service users with a written contract stating the home’s terms and conditions, however the financial agreement is not always clear. This could confuse service users about how their money is being used. EVIDENCE: Of the care files examined all included preadmission assessments and care plans from the referring agencies. There was evidence that careful planning is carried out so that the home is satisfied that they can meet prospective service user’s needs. One person who had recently moved into the home confirmed that they had visited the home several times before making the decision to stay. They commented, “I’m happy here, I know this is where I want to be.” Another service user commented, It’s good having xxxxxx in the house, I like talking to hxx.” West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 10 The home is currently carrying out person centred plans with service users and although this has not yet taken place with all service users, the outcome is positive. Records confirmed that the service user and their families have led the process and individual aspirations both long and short term, have been identified. All service users receive a contract describing the terms and conditions of their stay and the full cost of their fees and how these are to be paid. However for one person, it was not clear how the full amount of their mobility allowance was being used. If a person agrees to pay towards the running of the home’s vehicle this must be agreed in the contract, which must be signed by the service user or their representative and a representative of the Company. The manager agreed to address this with the Company’s finance department. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Each service user has a care plan that is easy to understand considers all areas of their lives and includes risk assessments. EVIDENCE: A good care planning system, that covers all health, welfare and social issues, is in place and any identified risks are addressed and reduced by risk management plans being put in place. The home is in the process of further developing the care-plan system so that they are service user led and recorded using the person centred approach. Two of the care plans examined were in this form and were made more accessible to the service users with the use of pictures and photographs. The manager explained how service user’s relatives had been positively involved in the developing of the plans and how this was also helping to maintain positive relationships between service users, relatives and the home. The guidelines in the care plans clearly identify the amount of support service users need with different tasks while at the same time promote service users West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 12 as people with dignity and self direction. One care plan recorded aspirations in short and long-term goals, for example a short term goal was to go on holiday to Blackpool, while the long term goal was to go abroad to Spain or France. This aspiration was confirmed in conversation with the service user. For another service user their goal was to attend a football match. Plans regarding how this was planned and achieved were clearly recorded. Staff confirmed that service users, independence is promoted and they are encouraged to take control over their own lives. Records confirmed this and action plans describing how personal goals are to be achieved were in place. Records also confirmed that the care plans are monitored by the service user and their key worker monthly and reviewed annually when other people involved in their lives are invited to attend. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in a variety of leisure and community based activities, and as a result live a valued lifestyle. The service supports service users’ rights and successfully supports them in maintaining relationships with family and friends. The food is of good quality and sufficient to meet the needs of service users. EVIDENCE: The home is making an effort to encourage service users to take control over their own lives and to develop lifestyles that are valued and based on individual preferences. One service user described how they are now able to get out and about independently, they stated, “ I have a bus pass now and I go to Sunderland, Gateshead and South Shields on my own.” A weekly activity sheet demonstrates the different activities service users take part in and any new activities and experiences are highlighted in an individual colour. The manager explained that the aim is to have more highlighted West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 14 activities each week. This chart also demonstrated the increased 1 to 1 work that is going on between individual staff and service users. Staff stated that this is so service users are given individual quality time at specified times of the week. Service users were observed being encouraged to clear up after lunch and to put personal laundry away. Entertainment equipment in individual bedrooms enables service users to listen to music and watch TV in the privacy of their own room if they choose. Service users, some supported by staff, discussed the variety of activities that they enjoy including; a visit to the football match, an evening meal out, a visit to a nearby pub with a family member and a ride out to Seaburn. Holiday destinations were also discussed and one person who in the past had chosen not to go on holidays explained how they had decided to go to an exhibition and stay overnight in a hotel. A light lunch was taken at the dining table with the service users and staff during which time much of the discussions took place. This was a pleasant experience where nutritious food that service users had chosen prior to the meal, was served. Records proved that nutrition is monitored and healthy eating is promoted. Service users openly spoke about a family members and records and photographs confirmed that the home encourages contact with family and friends to be maintained. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users personal and healthcare needs are met in a flexible but consistent manner, with the aim of allowing service users to take the lead. Medication arrangements are appropriate for the needs of service users and are managed in a safe manner. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Although staff support service users to attend health appointments service users, if they are able, are encouraged to take the lead. One service user was observed to approach the manager to confirm the time of their chiropodist appointment and to ask who would be supporting them. The manager confirmed the planned arrangements and also reminded them to take with them the letter of appointment that they had received in the post and a list of their medication. The service user carried out this confidently. Records confirmed that specialist health professionals are involved in service users lives where appropriate. The manager has received positive feedback from a Community Psychiatric Nurse who has been involved in one service West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 16 user’s life for several years and who stated “ I’ve never seen xxxxxx with so much confidence.” Records also included a very positive letter from another healthcare professional who commented on the improvement of another service user. Staff have received training regarding mental health awareness that was based around one service user’s diagnosis. Staff commented that the training was good and helped them understand the needs of the service user. Appropriate equipment has been put in place to address the physical and personal needs of a service user new to the service. This was as a result of an assessment carried out by an occupational therapist prior to the person moving in. An overhead tracking system has been fitted in the bathroom to provide safe and comfortable transfers via a hoist from chair to bath and a slide and glide chair provides transfers from chair to toilet. Such equipment and procedures also protects and promotes the privacy and dignity of the service user. A clear recording system in the care plans, that is service user led and clearly promotes service users’ independence, provides guidelines for staff to follow when supporting service users’ personal needs. Risk assessments that promote service users’ safety are also included and stored at the back of the care file. A discussion took place with the manager regarding how the risk assessments might be more effective if stored directly with individual care plans. Staff confirmed that they have attended training in the administration of medication and their knowledge and the way medication was stored reflects this. One service user is currently being appropriately supported to take control of their own medicines. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Arrangements are in place to help protect service users from abuse and to seriously address complaints and concerns about the service. EVIDENCE: The home has a comprehensive complaints procedure that is picture format in an attempt to make it more accessible to the service users. The Complaints Book has been developed in the person centred approach with the aim that service users will feel more confident that their concerns and complaints are taken seriously. The outcome and complaint from one service user about a member of staff was appropriately dealt with and recorded by the manager who stated that as a result the relationship between the service user and member of staff had developed and improved. Staff and records confirmed that staff have received training regarding the local authority’s Protection of Vulnerable Adults (POVA) procedures. Staff confirmed the action they would take if an abusive incident was observed or reported to them. Staff also confirmed that they have received training in relation to Verbal and Physical Aggression. There is a clear system for the recording of monies kept for service users. Records provide evidence how money has been spent and receipts are kept. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 18 Each service user has an individual bank account. A local authority is Appointee for one service user, however the service user is not receiving their weekly allowance, neither are they receiving an account from the local authority demonstrating how the money is being managed. The manager agreed to address this with the local authority concerned. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The standard of the environment within this home is good providing service users with a clean, attractive, safe and homely place to live. EVIDENCE: The standard of the furnishings and fittings in this home are good presenting an attractive and comfortable environment for service users to live. Advantage of using light coordinating colours for the decorating and furnishings has given a feeling of space and calmness. Service users were observed sitting in comfort in their surroundings and two service users who rely on wheelchairs for mobility were observed moving around the ground floor with ease. All service users have individual bedrooms that are decorated and furnished to reflect individual personalities. The laundry has been refurbished with new units and decorated. This has resulted in a brighter environment. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 20 The windows in this room have locks fitted but they are not fitted with window restrictors, this means that the windows cannot be left open when the room is unoccupied. The manager confirmed this and stated that it is the case throughout the house, as none of the windows are fitted with restrictors. This means that all windows are locked at night or when the room is unoccupied leaving service users with no choice of sleeping with the window open. A discussion took place with the manager regarding the safety of the service users and their right to choose. The manager hopes that this issue will be resolved when the windows are replaced in the near future. In the meantime to further protect service users risk assessments must be put in place. The home is well maintained and kept clean and tidy, however the ceiling above the bay window in the lounge may need attention as the ceiling paper is coming away. The radiator cover in the first floor bathroom is showing signs of wear and tear and needs to be repaired or replaced. Staff confirmed that they have received training regarding infection control. The cleanliness of the home reflected good cleaning schedules. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Robust recruitment & selection procedures and regular training opportunities ensure that service users are appropriately supported and protected by a competent and qualified staff team. EVIDENCE: Staff were observed to work with enthusiasm and spoke positively about the service users’ development, one said “I love working here.” One service user commented, “ the staff are nice, we all get on well together.” The staffing needs for this home have been reviewed since the last inspection and as a result the minimum number of staff on duty has risen from three to four. This was the result of the manager successfully renegotiating the resources needed, to address the needs of the people using the service, with the contracting agencies. The manager and staff stated that the increase in staffing has not only improved time available to address the care needs of the people using the service, but also allows service users to benefit from one to one work with staff in the local community. This has enhanced service users’ lives. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 22 However there are currently staff vacancies that means bank and agency staff are being used to fully staff the home. The manager stated that every effort is being made to use the same bank or agency staff so that consistency is kept for the benefit of service users. The manager was advised to fill the vacancies as soon as possible. The manager confirmed that staff resources are used flexibly to allow different activities to take place at different times of the day. She also confirmed that staff are delegated to different duties for example one member of staff has responsibility for the health and safety issues around the home and another is responsible for the ordering of food and the compilation of the menus. A sample of staff files were examined and these confirmed that good recruitment procedures are followed. Staff and the training matrix confirmed that mandatory training is up to date and all staff have completed NVQ. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The manager, who is well supported by her staff team, provides good leadership and runs a service that has effective monitoring systems that are focussed on the best interests of the service users. EVIDENCE: The manager was employed to manage this home in January 2006. She is now registered and has commenced working towards the Registered Managers Award (RMA), which she aims to have completed by April 2007. She confirmed that she is up to date with mandatory training and attends training sessions related to her role. The manager is experienced in working with people with learning disabilities and demonstrates enthusiasm towards further developing this service. She has an open and organised approach, keeps up to date with new legislation and ideas and appropriately delegate’s responsibilities to her staff team. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 24 This service has a quality assurance system in place that includes the provision for asking service users their views on the service provided. This is monitored internally monthly by the manager and annually by an external person. This ensures that the home’s policies and procedures are being followed and that the service is lead in the best interests of the service users. Health and safety procedures are in place and staff practices reflect acknowledgement of these. The fire and accident records are appropriately kept up to date. West Lodge DS0000015758.V304224.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 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 YA5 Regulation 5(b) Requirement The registered manager must ensure that the service users’ contract includes full details regarding the break down of fees paid and the amount paid towards the running costs of the home’s vehicle. The service user or a representative of the service user and a representative of the Company must sign this contract. . The registered manager must ensure that where an appointee is dealing with a service user’s finances including their pensions, clear accounts, including income and outgoings, must be made available to the service user. The registered manager must ensure that the premises are kept in good repair with particular attention to the ceiling above the bay window, and the radiator cover in the first floor bathroom. Risk assessments must be put in place regarding the risks posed when windows are left DS0000015758.V304224.R01.S.doc Timescale for action 30/09/06 2 YA7 YA23 17(2) Schedule 4 (8)(9) 30/09/06 3 YA24 YA42 23(2) 30/09/06 4 YA24 YA42 13(4) 30/09/06 West Lodge Version 5.2 Page 27 5 YA33 6 YA37 open without restriction. The manager must ensure that window restrictors are fitted to all windows so that any risks to service users safety are reduced. 18(1)(a)(b) To ensure continuity of care the registered manager must address the current staff vacancies. 9(1)(2) The registered manager must complete the Registered Managers Award and NVQ4 in Care. 30/09/06 30/04/07 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 Refer to Standard YA9 YA19 Good Practice Recommendations Risk assessments might be more effective if recorded directly next to the relevant individual care plan. West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI West Lodge DS0000015758.V304224.R01.S.doc Version 5.2 Page 29 - 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!