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Inspection on 19/07/05 for West View

Also see our care home review for West View for more information

This inspection was carried out on 19th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prior to the inspection a large number of questionnaires completed by residents and relatives were returned confirming their satisfaction with the service provided. Residents spoken to during the inspection confirmed that they liked the staff and were happy with the service and the accommodation provided. The home is newly built and provides spacious, well furnished, light and comfortable, single room with en-suite accommodation.

What has improved since the last inspection?

Although this was the first formal inspection, an additional visit was made in May 2005, which resulted in a report with immediate requirements. Since that visit, infection control practices have improved. A separate pharmacist report identifies the action taken following the visit in May.

What the care home could do better:

Standard 7It is acknowledged that the manager and her staff have worked hard to get the centre up and running. West View provides both nursing and residential care and various ways of working had to be harmonised. As a result, the care planning format is not yet fully integrated although systems to facilitate this have now been introduced. Standard 27 The arrangement for the trained nurse`s hours on night duty must be reviewed. Standard 30 Induction training is in need of review. A training matrix is recommended to ensure adequate training of all staff at all times. Standard 31 Job descriptions may need to be reviewed to accurately reflect staff`s role and responsibilities. Standard 37 A record of visitors is required to be maintained. Accident records must be stored in accordance with the Data Protection Act 1998. Standard 38 The requirements of the environmental health officer must be carried out. The centre must obtain a copy of the Fire Risk Assessment. Accident records must evidence the action taken to deal with the situation and should identify any preventative measures.

CARE HOMES FOR OLDER PEOPLE West View Plummer Lane Tenterden Kent TN30 6TX Lead Inspector Lisbeth Scoones Announced 19 July 2005 9:30 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 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 View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service West View Address Plummer Lane, Tenterden, Kent TN30 6TX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01580 261500 Kent County Council Caroline Joan Heffernan Care Home with Nursing 60 Category(ies) of Old age (over 55 years of age x 45; dementia registration, with number (over 55 years of age) x 15 of places West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection NA Brief Description of the Service: West View is an innovative service, registered in April 2005, and aims to provide a range of services to meet both the health and social care needs of 60 male and female residents aged 55 and over. Accomodation is on two floors each providing care for 30 residents. Nursing care and recuperative care is provided in the 15 bedded Benenden East and 15 bedded Benenden West units on the first floor accessed by two passenger lifts. The ground floor comprises two units: The Lindens and Wittersham. Long term residential care for 15 residents and up to 2 of places for short stay respite care is provided in the Lindens. Wittersham provides long term dementia care for 15 residents and up to 2 of these may be used for short term respite care. West View Integrated Care Centre is newly built and situated in Plummer Lane. It offers magnificent views of rural countryside and provides ample car parking. There is a secure garden as well as other gardens, walkways and a pond to the front of the building. The market town of Tenterden with bus services, railway station and other amenities is nearby. The town of Ashford is approximately 15 miles away. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first formal inspection, which was undertaken by Lisbeth Scoones and Sally Gill, regulatory inspectors and Christine Hastie and colleague, pharmacist inspectors. The inspection took place over two days and comprised discussions with the manager and deputy manager, other staff in all units, conversations with residents and a visiting relative, a comprehensive medication audit, a tour of the premises and the examination of care and other records. Throughout the inspection, the manager and the deputy manager assisted the inspectors. At the time of the inspection occupancy comprised 26 permanent and 4 respite residents on the ground floor. There were some vacancies on the first floor which comprise two 15 bedded units for intermediate/recuperative and nursing care. The pharmacist inspectors recorded their findings in a separate report and reported improvements made. At this inspection, they made two immediate requirements. What the service does well: What has improved since the last inspection? What they could do better: Standard 7 West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 6 It is acknowledged that the manager and her staff have worked hard to get the centre up and running. West View provides both nursing and residential care and various ways of working had to be harmonised. As a result, the care planning format is not yet fully integrated although systems to facilitate this have now been introduced. Standard 27 The arrangement for the trained nurse’s hours on night duty must be reviewed. Standard 30 Induction training is in need of review. A training matrix is recommended to ensure adequate training of all staff at all times. Standard 31 Job descriptions may need to be reviewed to accurately reflect staff’s role and responsibilities. Standard 37 A record of visitors is required to be maintained. Accident records must be stored in accordance with the Data Protection Act 1998. Standard 38 The requirements of the environmental health officer must be carried out. The centre must obtain a copy of the Fire Risk Assessment. Accident records must evidence the action taken to deal with the situation and should identify any preventative measures. 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 View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5, 6 1 The home’s statement of purpose and service user guide provide residents with the information they need to make an informed decision about the services the home provides. 2 All residents or their representative sign a placement agreement. 3 All residents move into the home having had their needs assessed and been assured that these needs will be met. 5 Prospective residents and their relatives have an opportunity to visit the home and assess the quality of the service and suitability of the home. 6 Residents assessed and referred as requiring intermediate (recuperative) care are assisted to maximise their independence and return home. EVIDENCE: 1 The statement of purpose and Service User Guide have been updated and meet the standard. It was agreed that both documents are regularly reviewed reflecting changes as they occur. The Statement of Purpose was West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 9 seen on display at the desk in the entrance hall and copies of the Service User Guide in individual bedrooms. Residents said that they were aware of the information provided in the guide. It was said that inspection reports would be available in the reception area. 2 As is stated in the Statement of Purpose, all residents will be presented with and required to sign a placement agreement as appropriate to the level of service required detailing those services and facilities that are to attract a chargeable fee. There is no charge to residents assessed as requiring nursing or rehabilitation/recuperative care. 3 The centre has procedures for admission covering the various types of care on offer. For intermediate care, a flow chart identifies the process. For those residents requiring long term residential or dementia care, the process would include an assessment by the care manager and preadmission assessment by the manager of the centre. For those residents requiring nursing care, admission criteria would be determined through a joint assessment process. 5 The manager said that wherever possible, prospective residents are invited to make an introductory visit before agreeing to stay at the centre. As stated in the Statement of Purpose, “a month’s trial period is always given before taking permanent residency.” A visitor said that she was spending the day at the centre to see if she would like to become a permanent resident. 6 The centre has dedicated rehabilitation facilities, which include equipment for therapy and treatment. Specialist services from relevant professions including physiotherapists and occupational therapists are provided to meet the assessed need of those residents admitted for rehabilitation. Residents spoken to explained the planned package of care, their hopes for recovery following surgery and their progress to date. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 7 There is no clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet the residents’ needs. 8 Residents health care needs are well met with evidence of good multidisciplinary working. 9 10 Medication issues are covered in a separate report. Residents are treated with respect and with due regard for their privacy. EVIDENCE: 7 Those care plans for residents requiring recuperative care do not as yet provide a comprehensive integrated programme of care. Currently, those records completed by physiotherapists are kept separately from the centre’s care plan. It is recommended that these are integrated and/or crossreferenced thus providing an opportunity to report on all care provided. A resident and a relative commented that they are not fully aware of the physio programme devised. The centre’s staff comment in daily records on physio West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 11 provided whilst the instructions were kept in another file. The manager and nurse in charge agreed with this observation and said that a new integrated (computerised) care-planning format has been devised. Those care plans completed for residents assessed as requiring residential and dementia care lacked a uniform approach, were in some areas incomplete and provided insufficient detail to ensure that residents needs could be fully met and independence promoted where possible. This was discussed at length during the feedback session with particular emphasis on continence management, eating and drinking, night care and professional input. Risk assessments also lack detail and in some cases did not contain any instructions for staff to minimise the risk that was highlighted. A manual handling risk assessment must be specific in how many carers are required for each manoeuvre and which manoeuvres must be used in which situation. 8 The CART team comprises physiotherapists, occupational therapists and community district nurse and provides care and support to those residents admitted for recuperative care. The centre employs its own physiotherapist. The inspectors met with the intermediate care team community nurse who oversees the 10 social care `beds. All staff are trained to treat and prevent the development of pressure ulcers and to promote continence. Residents have access to dental and chiropody services. 9 See separate report 10 Residents said that they liked the staff and were treated with courtesy and respect. Staff interacted with residents and each other in a pleasant and unhurried manner. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 12 13 14 15 Residents are provided with choices in relation to their chosen lifestyle. Residents remain in contact with their family and friends. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome, balanced and varied diet. EVIDENCE: 12 Those residents admitted for recuperative care said that they have a choice in relation to leisure and social activities, food and routines of daily living. Leisure facilities for those residents receiving long-term care are being developed and currently include bingo, daily newspapers, word games, beauty therapy and the shop. A reminiscence room has been set up in 1930’s style, the contents of which many residents and their relatives have contributed to. The manager said that sensory equipment had been purchased. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 13 13 The centre operates an open visiting policy. A visitor said that she was always made to feel welcome and that staff involve her in her relative’ care. The centre employs a number of volunteers who run a small shop where residents can buy newspapers, toiletries and sweets. See also standard 29. 14 For those residents admitted for recuperative care, staff enable the residents to be as independent as possible in preparation for going home. Staff encourage all residents to make their bedrooms as personal as they wish with their own belongings. Rooms visited looked comfortable and homely. It was said that residents are allowed to hang pictures on their bedroom walls. 15 The catering arrangements at West View are provided by Shaw Health Care and the kitchen is well equipped and staffed. Residents complete menu cards and choose what they wish to eat. Residents said that they enjoy the meals with comments that “its as good as a first class hotel” and “there’s plenty of choice for all meals”. Three meals a day are provided as well as a snack meal in the evening if required. Nutritional assessments are undertaken and diets catered for. A new chef has recently been appointed who said that the menus are to be reviewed and that residents would be consulted in the process. Meals served looked appetising and were well presented. The environmental health officer recently inspected the home and made two requirements. See standard 38.4 Every unit has a kitchen from which the meals are served. Additional kitchens are available to be used by residents and their relatives. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 16 Residents know that their complaints will be listened to. 18 Staff are trained in adult protection issues thus ensuring that residents are protected from abuse. EVIDENCE: 16 Residents said that they feel comfortable with the staff and would feel confident to discuss any complaints they may have. There is a complaint procedure, which is included in the Service user Guide. To date, no complaints have been received and one resident commented that “there is no fault to find”. 18 Staff are provided with in-house adult protection training. See also standard 30 in respect of a training matrix. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 25, 26 19 The centre provides a safe and well-maintained environment. 20 Residents have access to safe and comfortable indoor and outdoor communal facilities. 21 Sufficient and suitable lavatories and washing facilities are provided. 22 Specialist equipment is provided to promote and maximise residents’ independence. 23 24 25 26 Residents are provided with a room that meets their needs. Residents are provided with a safe and comfortable bedroom. Residents are provided with a safe and comfortable environment. The home is clean, pleasant and hygienic. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 16 EVIDENCE: 19 Shaw Health care is responsible for maintaining the building both in respect of routine maintenance and renewal of fabric and decoration. The grounds and gardens are attractive and accessible to residents. 20 All communal areas are well furnished with a variety of chairs and other furniture. One resident said that the footstools are too low to “put her feet up comfortably.” 21 All bedrooms have their own en-suite facilities comprising a shower with pull down seat and toilet. Assisted baths are available throughout the centre. 22 A large number of equipment and facilities for treatment and rehabilitation are available at the centre. 23 The centre has 60 en-suite bedrooms situated over two floors accessed by two passenger lifts. Each floor offers two units of 15 beds each. Each unit has one adjoining room. Residents said they liked the décor and of their rooms. 24 The rooms are well furnished and tastefully decorated. As stated in the Service User Guide, “All bedrooms have privacy locks on doors and a lockable facility to secure valuables and personal items”. Although one resident commented that they “did not have a key but would like one”. 25 Safe heating and adequate lighting is provided. 26 The responsibility of the domestic and laundry provision is with Shaw Health Care. The centre was clean with no unpleasant odours. An infection control policy and procedures are in place and staff training provided. Clean sluices were noted. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 27 Staff are provided in sufficient numbers and skills mix to meet the needs of the residents except for one hour during the night shift. 29 30 Residents are supported by the home’s recruitment policy and practices. Staff are trained and competent to do their job. EVIDENCE: 27 The centre offers day care and is registered to provide residential, dementia and nursing care. In respect of nursing care, registered nurses and health care workers are employed on a secondment basis. As quoted from the Statement of Purpose, “A secondment of service agreement exists which forms the protocols adopted by the employing authority and the area PCT to enable the provision of nursing care within West View.” The centre has been accredited to provide placements for first year student nurses. Staff had previously raised concerns regarding the level of staffing during the mornings particularly on the Wittersham unit however during the inspection staff confirmed that staff were now in a better routine after the move and they felt it was adequate. Both Wittersham and the Lindens are each staffed by three carers, with a senior carer also on duty across the two. Duty rotas examined would indicate that for each shift, sufficient senior and unit staff is provided. During the inspection it was said that for one hour West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 18 during the night shift, the registered nurse is on call but not actually on duty. This practice contravenes the Regulation, which requires a registered nurse to be on duty at all times. The centre is still recruiting new staff and until fully staffed, uses (its own) agency staff to fill the gaps although staff said that on occasion they had run down on rota numbers. 29 Recruitment procedures were discussed and a number of staff files examined. These indicate good recruitment and selection procedures. CRB checks are requested and processed at head office, therefore the manager currently cannot evidence that a disclosure has been applied for although she does receive the outcome of the POVA check. Not all staff files contained job descriptions or terms and conditions of employment. The need for volunteers to be CRB checked was discussed and it was agreed that the manager would seek clarification in this respect. 30 The assistant manager is in charge of induction and other training. Three care staff are currently being inducted. It was said that the centre does not provide TOPSS Foundation training but favours the NVQ route. The manager provided a list of training planned and undertaken. The merits of a training matrix were discussed. The inspectors were told that the induction is to TOPSS standard however the programme did not contain sufficient detail or any timescales to evidence this. The assistant manager said that the induction programme is one day and contains an overview of fire, moving and handling, care plans, confidentiality, infection control, health and safety, handover and report giving. Staff’s competency is not currently evidenced as checked during or after induction which would indicate that the induction is not to TOPSS specification. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38 31 The manager is supported by senior staff in providing leadership throughout the home. 32 Residents live in a home that provides an open and positive management approach. 33 Monitoring systems ensure that residents’ views are included in establishing whether the home meets its aims and objectives and Statement of Purpose. 36 Staff are supervised but no records were available to judge whether the supervision meets the standard. 37 Not all records are maintained and stored in accordance with the Data Protection requirements. 38 Residents’ health, safety and welfare are promoted and protected except for recent action required by the environmental health officer. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 20 EVIDENCE: 31 Mrs Caroline Heffernan, a registered nurse, is the registered manager and has 5 years experience in managing care homes. She has a management qualification and is supported by a Head of Service, Operational Manager and recently appointed Business Officer. The assistant manager is a registered nurse. A senior sister heads the nursing units and senior team leader the residential and dementia units. All staff have been provided with job descriptions relevant to their role and responsibility although not always evident on files. The need for these to be reviewed was discussed. 32 Through staff and residents meetings, the manager ensures involvement from staff and feedback from residents and their relatives. Residents said that staff are interested in their views. 33 Formal monthly monitoring visits are made and comprehensive reports written. A copy is submitted to the CSCI. These visits include discussions with residents and staff and details of staff training. 36 Staff said that they recently had received formal supervision. It was ascertained that not all senior staff had had supervision. Records pertaining to supervision sessions were not requested on this occasion. Arrangements are in place for clinical supervision for nurses and health care staff. 37 Accident records are maintained and stored in a way that contravenes the Data Protecting requirements. This was discussed with the manager at the time. It is further required that a record of all visitors to the care home, including the names of visitors be kept. The Statement of Purpose makes reference to this requirement on page 11. 38 There was evidence of statutory training including recent fire safety awareness. Signage on bedrooms doors stating that these should be kept shut give confusing information as, according to the Fire Officer, these do not have to be kept shut. The manager is aware that this signage gives confusing information and said that as yet there were no plans to remove them. The need for the centre to have a copy of the Fire Risk assessment was discussed. During every shift, a nominated Fire Officer and First Aider are on duty. Accident records are maintained but those examined do not sufficiently reflect the action taken. It was further recommended that these are adequately completed and audited. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 2 2 2 West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 22 Yes 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 7 Regulation 15 (1) Requirement That the registered person shall prepare a plan as to how the service users needs in respect of health and welfare are to be met. That at all times a suitably qualified registered nurse is working at the care home That a record of all visitors to the care home, including the names of visitors be kept That accident records are maintained in accordance with the Data Protection Act 1998 That the requirements made by the environmental health officer be met within the agreed timescale Timescale for action 31 August 2005 2. 3. 4. 5. 27 37 37 19.5 and 38.2 18 (2) (3) (a) (b) 17 (2) Schedule 4 (17) 17(1)b 16(2) 30 September 2005 31 August 2005 31 August 2005 In accordance with EHO instructions 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 27 29 Good Practice Recommendations That all staff have a job descriptions reflecting their role and responsibility That staff files contain evidence of statements of terms H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 23 West View 3. 30 4. 5. 36 38.2 and conditions and current job description That a staff qualification and training matrix be developed and maintained to evidence a trained and competent workforce. Evidence to be provided that the induction training meets TOPSS standards That all staff receive supervision in accordance with the standard That the centre obtain a copy of the Fire Risk Assessment. West View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU 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 View H56-H05 S63680 West View V226797 190705 Stage 4.doc Version 1.40 Page 25 - 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. 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