Inspection on 25/07/07 for West Lodge

This inspection was carried out on 25th July 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 no outstanding requirements from the previous inspection report, but made 2 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 22/08/06

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 25th July 2007 09:30 West Lodge DS0000015758.V340547.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.V340547.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.V340547.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.V340547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 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 £727.47p per week. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 7 hours over one day in July 2007. The judgements made are based on the evidence available to the inspector during the inspection. Discussions took place with five service users and five members of staff as part of the inspection process. As some of the service users do not have effective verbal communication, their satisfaction with the service was interpreted through the observations of body language, interaction with staff, discussions with staff and the examination of records. This showed that all were satisfied with the service and the care and support given by staff. The inspector looked around the building and a sample of staffing and service users’ records was inspected and the inspector took a light lunch with service users. 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. Each person who lives at the home has a copy of this book in his or her care file. People are invited to look around the house before deciding to move in. This helps people to make an informed decision about where to live. It is very comfortable inside West Lodge. There is appropriate furniture and the rooms are nicely decorated. It is well looked after and kept very clean and tidy. The staff know the service users well and they 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 service users and staff makes everyone visiting West Lodge feel very welcome. Service users said they are happy living here. One service user said: “This is a nice home, it is a nice place to live.” Relatives, when asked what they thought the home does well answered: “Keep us informed.” West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 6 “Gives a comfortable home environment and care.” 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: The manager must make sure that the information in the Statement of Purpose is accurate so that people reading it are not mislead. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 7 If any door in the home needs to be kept open a mechanism that is connected to the fire alarm system must be fitted so that in the event of the fire alarm sounding the door closes automatically. The manager should aim to complete the Registered Managers Award within the next 8 months. This is so the service users live in a home and receive a service led by a fully qualified manager. 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 Lodge DS0000015758.V340547.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.V340547.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good information about the service. This is in a format that is easy to understand. This helps service users to make an informed choice about where they would like to live. A contract is in place that informs service users of the home’s terms and conditions and the fees to be paid. Good multidisciplinary preadmission assessments demonstrate service users’ needs and aspirations and assist the home to make an informed judgement as to whether they can meet these. EVIDENCE: The home has developed a Statement of Purpose and a Service User Guide. Both documents have recently been reviewed and updated to ensure that they include up to date information about the service. One small error relating to the name of the Responsible Individual was brought to the attention of the manager. Each service user has a contract that describes the home’s terms and conditions and the full fees charged. A clear breakdown of the fees informs West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 10 service users or their representatives of the contribution they need to pay and how the rest of the fees will be paid. There is also a separate contract in place in relation to the money paid towards the running of the home’s vehicle for each service user. This clearly explains how service users’ individual mobility benefit is broken down towards this cost. Both contracts are signed and kept in individual care files. The home has a policy that states that prior to anyone moving into the home a full assessment of need is carried out by the referring agency and by the home. These are evident in individual care files and enable the service to make an informed decision whether the home can meet the identified needs. Visits to the home by the prospective service user are arranged. This enables the people living at the home to meet the prospective service user and to enable a decision to be made whether the placement will be compatible to everyone. The care plans currently in place reflect the information in the assessments and are regularly monitored and adapted to address changing needs and aspirations. This process is currently being carefully monitored for one service user who regularly conveys to staff that they are not happy with their placement at West Lodge. The behaviours exhibited also suggest that the placement is not appropriate. A multi disciplinary meeting has been arranged to address this. West Lodge DS0000015758.V340547.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. 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 using available evidence including a visit to this service. Care plans guide staff to appropriately support service users’ care needs and enable staff to support service users to make choices about their lives and are an outcome of ongoing assessment. Service users are supported to develop their independence while at the same time they are supported to take risks safely. EVIDENCE: There is a care plan in place for each service user living at this home. The information recorded in them is current and clearly guides staff to effectively address the individual service users’ personal, social and emotional care needs. Clear guidelines are in place to support individual service users: one with part of their life that they were finding difficult and another with developing their independence in relation to independent travelling. Both directed staff to support the individual service user effectively and consistently. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 12 The key worker monitors the care plans monthly and annual reviews take place when people involved in service users’ lives are invited to discuss the plan of care in place and any other issues about the placement. Service users are empowered to lead their care plans. They are written with a person centred approach and they are illustrated with pictures so that service users have access to what is written about them. A key worker system is in place that works effectively and gives consistency to service users. The manager confirmed that key workers and service users are matched sensitively for compatibility. Service users spoke positively about staff members in general and in particular their key worker. The key worker is responsible for making sure that the information recorded about individual service users is kept up to date. The manager and staff have worked hard to develop an effective care planning system. This is well organised and to make it easy to access information is divided into different files, for example there are separate Health, Support and Financial Plans. Service user’s individual goals and the action taken to achieve them are recorded in a separate file. All of the separate files are kept in individual plastic storage boxes with the photograph of the individual service user on the front. Risks are identified and addressed appropriately. Risk management plans are put in place to reduce the risk of harm to the service user, and are an integral part of the care plan. West Lodge DS0000015758.V340547.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to live appropriate and fulfilling lifestyles both in their own home and the local community. The service supports service users’ rights and promotes their independence, while it also successfully supports them in maintaining relationships with family and friends. Meals are healthy, nutritious and attractive, and are prepared to meet the individual dietary needs of each service user. EVIDENCE: All of the service users have individual weekly activity programmes that are evident in a “diary” that is part of their care plan. These vary according to individual preferences but confirm well-organised and active lifestyles. Some West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 14 activities are mainly centred in the community while others are based in the home. The home is run and organised to promote the recognition of respect, privacy and the rights of service users. Staff working practices reflect this. Service users’ rooms are respected as their private space and service users move around the home with confidence, demonstrating ownership of their surroundings. So that service users are supported to take control over their lives individual “diaries” identify for them different tasks, for which they are responsible. For example different appointments they need to attend, menus to be chosen and developed in preparation for the weekly shopping and accidents and incidents that need to be discussed and addressed. This is proving to be a successful process. Service users were aware of the order of their day and were able to discuss what activities were planned. One service user was observed reminding a member of staff of the date and time of their next appointment with a healthcare worker. So that individual activities are purposeful and successful care plans include clear guidelines for staff to follow in relation to them. Staff confirmed that a consistent approach when supporting service users usually results in success and in the routine or task being achieved effectively. This has been particularly helpful for one service user, who previously was finding the transition process of moving into an adult world difficult, but through a consistent approach from staff is now more independent and in control of their life. Service users were observed clearing tables and taking their dishes to the dishwasher. A member of staff sensitively encouraged one person, who is reluctant to carry out this task, with positive effect. This approach is recorded in the care plan. One service user is encouraged to iron their clothes and clear guidelines direct staff to be consistent in their approach when supporting this task. A risk assessment is also in place in relation to this activity. Service users discussed the holidays they had enjoyed. One person discussed the days away they have planned, as they prefer to make the home their holiday base. Staff support service users to maintain contact with families and friends. A support plan is in place regarding a relationship that is currently developing between a service user and a person from outside of the home. Every effort is in place to give the service user autonomy over developing the relationship West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 15 independently, while at the same time the risk of their vulnerability is monitored. A successful open evening was arranged by the home to which friends and families were invited. A varied nutritious menu is offered at the home that caters for individual preferences and needs. The home has recently been awarded the Healthy Home Award. The award is promoted and assessed by Sunderland Council and Environmental Health and is open to all care services in the borough. It is the first time this award has been given to a small home so everyone at West Lodge is particularly proud and delighted at this success. Different standards are assessed including all aspects surrouding food and food allergies, menus and food handling as well as other issues such as the promotion of Equality and Diversity, Health and Safety and Training. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are met in a flexible but consistent manner, reflecting a healthy lifestyle. Medication arrangements are appropriate to the needs of service users and they are managed safely and appropriately, ensuring that the welfare of the service users is safeguarded. EVIDENCE: Service users are supported to register and attend healthcare practices in the local community. Visits to the GP, dentist’s opticians and other healthcare professionals are recorded in individual care files, with the outcome of the visit. The home has developed individual Health Care Action Plans that are recorded together in one file. The manager emphasised that having all relevant information about a person’s healthcare needs together proves helpful when service users attend healthcare appointments and in the event of a service user being admitted to hospital. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 17 Staff from the home and healthcare officials involved in the lives of individual service users work closely together. Healthcare needs are clearly recorded in the care files and developed as a care plan if needed. Any health or behaviour changes that are observed by staff are clearly recorded and if needed action is taken to gain specialist healthcare advice. The guidance given is recorded in the care plan. This is particularly evident in relation to challenging behaviours. Clear guidelines in one care plan, as advised by a psychologist, guides staff to appropriately support a service user in relation to this. The guidelines also support other service users and protect them from potential harm. Appropriate equipment has been put in place to reflect the assessed physical and personal needs of service users with physical disabilities. 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 the procedures in place for its use protect and promote service users’ privacy and dignity. Staff support service users with their personal tasks in a discreet and respectful manner. Staff confirmed that they have attended training in the administration of medication and their knowledge and the way medication was stored and administered reflects this. One service user is appropriately supported to take control of their personal medicines. A risk assessment is in place regarding this. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place which 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 is developed in a person centred approach with the aim that service users will feel more confident that their concerns and complaints are taken seriously. The outcome of a past 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 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. The home is currently addressing an allegation of abuse made by a service user via the local authority’s POVA procedures. Staff confirmed that they have received training in relation to Verbal and Physical Aggression. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 19 There is a clear system for the recording of service users’ monies. Each service user has an individual bank account and records and receipts of purchases demonstrate how money is spent. Each service user has an appropriate care plan in place to guide staff how their money is stored, how it is to be monitored and the support they need to access it and use it. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable, clean, safe and decorated and furnished to a high standard. It therefore provides service users with spacious, private and communal spaces in which 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. The use of 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. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 21 The separate laundry is well furnished, with appropriate facilities and domestic machinery. The windows throughout the home including the laundry are now fitted with restrictors. This means that the windows can now be left open when fresh air is needed or when service users choose. The home is well maintained and kept clean and tidy, however although the wall paper on the ceiling above the bay window in the lounge has been repaired since the last inspection, this continues to come away from the ceiling. This again should be addressed. Staff confirmed that they have received training regarding infection control. The cleanliness of the home reflects this and also the good cleaning schedules in place. A patio door leads directly into the gardens that are neat and tidy and accessible to service users. It was noted that the office door was kept open with a rubber chock. The manager confirmed that this way of keeping the door open is only used when people are in the office. The manager was advised that if a fire door needs to be kept open an electronic device that is connected to the fire alarm system must be fitted. This is so that in the case of the fire alarm sounding the door will be released to close automatically. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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: The staff at this home work with enthusiasm and are focussed in their role. Although there has been a high turnover of staff in the past 12 months and recently recruited staff vary in their range of experience and qualifications in care, a strong competent staff team has developed. All new staff follow a comprehensive induction training schedule based on the Skills for Care Induction standards. Staff access this programme on the home’s computer E-Learning network and the work completed is assessed by an independent assessor. Once complete staff enrol for NVQ courses. All staff are up to date with mandatory training. Training in Equality and Diversity, Infection Control and the Safe Handling of Medicines is accessed via distant learning with a local college. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 23 Staff confirmed that they enjoy working at the home and all demonstrated their awareness and understanding of their roles. They interact with service users in a respectful and friendly manner. One service user said: “All the staff are good they get on with everybody, things are good here.” And a member of staff said: “It is really good working here, I love it, the training is excellent.” Examination of a sample of recruitment records confirmed that the company’s robust recruitment procedures are followed. Of the files examined all had completed application forms, 2 references and satisfactory CRB checks. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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 has worked at this home since January 2006. She is registered with CSCI (Commission with Social Care Inspection) and has commenced working towards the Registered Managers Award (RMA). The work completed towards NVQ4 in Care is waiting to be verified. The manager is a facilitator for both Moving and Handling and Person Centred Planning, and has recently attended training regarding Equality and Diversity, Mental Capacity Part 2, Supervision and Appraisal and Budget Management. She is up to date with mandatory training. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 25 The manager interacts with service users and staff positively and in a supportive way. Staff felt they were well supported by their manager and could go to her for guidance and advice when needed. The manager and staff work together with service users to establish a good working ethos in the home. Policies and procedures are regularly reviewed to ensure that they are appropriate to the needs of the service users. A diagram on the wall of the home identifies the service plan for this year illustrating how the aims and objectives for the year are to be met in the form of a “pathway”. As objectives are accomplished this is mapped on the path. This is a good way to keep service users and staff involved in and informed about how the aims and objectives of the yearly plan are accomplished. There is a good quality assurance system in place the outcomes of which are recorded. The system is monitored internally monthly by the manager and annually by an external person. This ensures that the home’s policies and procedures are put into practice and that the service is led in the best interests of the service users. Risks identified throughout the home are monitored and addressed well. A recent visit from the fire department commended the home on the risk assessment and procedures in place regarding safeguarding service users and staff against fire. Accidents to both service users and staff are recorded and addressed satisfactorily. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 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.V340547.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 6(a) Requirement Timescale for action 31/08/07 2 YA42 13(4) The error made in the Statement of Purpose regarding the name of the Registered Individual must be corrected. The registered manager must 31/08/07 ensure that any door needing to be kept open is done so by fitting an electronic mechanism to it, so that in the event of a fire and the fire alarm sounding the door automatically closes. 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 Refer to Standard YA24 YA37 Good Practice Recommendations The paper that is coming away from the ceiling in the lounge should be repaired The registered manager must complete the Registered Managers Award and NVQ4 in Care. West Lodge DS0000015758.V340547.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Lodge DS0000015758.V340547.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!