Inspection on 16/05/06 for Westbourne Care

This inspection was carried out on 16th May 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbourne Care 05/04/07

Westbourne Care 29/11/05

Westbourne Care 08/11/04

Westbourne Care 24/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Westbourne Care 53/55 Stockfield Road Acocks Green Birmingham West Midlands B27 6AR Lead Inspector Joe O`Connor Unannounced Inspection 16th May 2006 10:30 Westbourne Care DS0000017002.V295206.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 Westbourne Care DS0000017002.V295206.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. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbourne Care Address 53/55 Stockfield Road Acocks Green Birmingham West Midlands B27 6AR 0121 764 4231 0121 764 4231 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) Mr Philip White Mr J Wilson Lorraine Heritage Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 29th November 2005 Brief Description of the Service: The service provides care and accommodation to eleven service users who have a learning disability. The building comprises two adjoining three storey houses of traditional style, which have been converted to form separate but adjacent accommodation. Service users are accommodated over all three floors of the premises and offers both single and double rooms. Although the buildings are adjacent the service users have chosen to occupy each house separately in terms of female and male service users. The communal facilities have therefore been duplicated in both households consisting of lounge, dining room and kitchen. Communal bathing and toilet facilities are provided throughout. The premises are close to local bus and rail links. Westbourne offers service users a choice of recreational facilities including television, radio, DVD and video. Most service users have these in their own rooms. There is also an option for service users to be connected to cable television in their rooms at their own expense. To the rear is a large, mainly lawned garden with some shrubs and pots. This area forms a popular recreational area where service users from both houses can spend time together. There is also a green house in which some service users enjoy growing plants. Access within the home for those with impaired mobility is problematic. Therefore the Registered Provider must remain vigilant to the possibility of increasing physical and sensory needs of service users in the future. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over one day. The Inspector had opportunity to talk to two service users and two members of staff and the Registered Manager. Two relatives and a Community Nurse visiting the service were also spoken with. Care practices were observed including interactions from staff. Parts of the premises were viewed. Service users care plans and risk assessments were inspected. Staff recruitment records and training records were examined along with records for health and safety. To find out how the service has performed since the previous inspection the report should be read with the unannounced inspection report 23 November 2005. The current scale of fees charged by the service is £679.47 per week. What the service does well: Service users live in premises where its outside features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not known. This provides them with a homely non-institutional setting. At the time of this inspection the service users were observed to receive friendly and professional support from staff. Observations were made of staff offering one service user a choice of how he would preferred to be shaved before going out to a Bingo hall later that day. It was good to see one service user who had previously been non communicative at previous inspections very cheerful and talkative with other service users and staff. The manager commented that the service user had come off all medication and was really pleased with the progress that had been made. The service users were looking forward to their holiday in Blackpool, which they had chosen themselves. The service users have a meeting every Sunday where they choose what they want to do and organise the food menu for the week. An examination of the records indicated service users were going out into the community participating in activities such as the cinema, bowling, bingo and to the pub. Two service users spoken with were positive about the support they were receiving. One showed how her bedroom had recently been re-decorated was pleased with the colour scheme chosen. Another service user spoke about his favourite football team Birmingham City and said that he could approach the manager if there were any problems. Two relatives provided comments about the service during the inspection. One stated that there was always a happy atmosphere when they visited. Another commented how inclusive they felt and would be invited by the manager to birthday and Christmas parties. The service is very positive in promoting and supporting service users with Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 6 personal relationships. There is a good balance of male and female staff to cater for the equal number of female and male service users. 85 of the care staff employed are qualified to NVQ Level 2 or above and the service recently won award from Solihull College for Employer of the Year for their commitment to staff development. What has improved since the last inspection? What they could do better: Improvements were still required with service users care plans to ensure they covered information regarding daily routines. They also must have evidence that the service user has been involved the development and review. A number of risk assessments were in need of updating as one sampled was found to have incomplete information while another was did not have a date of when it had been completed. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 7 The service was overdue a fire drill which should occur every six months. Medication management was to a good standard but it was recommended to the manager that spot checks were made of staff giving out medication to service users ensuring they are competent with this task. Overall the service has made improvements since the previous inspection that indicates based on the available information and visit to the service indicates that this is a good service. 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. Westbourne Care DS0000017002.V295206.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 Westbourne Care DS0000017002.V295206.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): 1, 3, 5 Quality outcome is good. Judgement has been made using available evidence including visit to service. There is information available for prospective service users enabling them to make an informed choice about where they live. Service users have new contracts informing them of what is paid for in the fee and any additional charges. Service users are well cared for by supportive and friendly support. EVIDENCE: The manager had made amendments to the Statement of Purpose since the last inspection, which included information about the sizes of the bedrooms and which aspects of the environmental standard the service did not meet. It also had information about the CSCI and how often care plans would be reviewed with reference to the requirements of the National Minimum Standards. There is a Service Users Guide and it was recommended to the manager that this included some visual images such as photographs or illustrations to assist those who had difficulty reading. Two service users records seen that the manager had addressed a requirement that their individual statement of terms and conditions make reference to whether transport costs would be covered by the service’s fee. Service users were needs were being met at the time of this inspection with staff providing friendly and positive support. They were also dressed in clothing that was appropriate for the climate of the day. Two service users expressed Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 10 their satisfaction with the support they were receiving. One commented, “Staff are always nice”, while another said how much he was looking forward to his holiday to Blackpool. Two relatives spoken with at the time of this inspection provided positive comments about the service. These included “There is always a happy atmosphere in the home and staff make feel included in everything”. Another said “My brother in law is well cared for, the staff and manager are always keep in touch with me”. One positive outcome observed was one service user who during previous inspections had communicated very little to other service users and staff. It was good to see how much the service user had become more confident, happy and chatted a great a deal. The manager stated that the service user had recently been taken off all medication and were very pleased with how much progress she had made. The service user was looking forward to the World Cup and was asking the manager for an England football shirt. Westbourne Care DS0000017002.V295206.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, 8, 9 Quality outcome is adequate. Judgement has been made using available evidence including visit to service. Care plans still require improvements in stating how the needs of service users are to be met. Service users are encouraged to make decisions about their lives and through the use of peer group meetings. Service users have risk concerning limitations on their independence in the home and in the community but these will need to be reviewed ensuring information reflects their individual needs. EVIDENCE: Three service users care plans were sampled at the time of this inspection. One sampled referred to a service user who communicated with Makaton and that among their leisure interests was a supporter of Aston Villa. Another sampled stated that the service user required assistance to manager their personal finances and that they were able to complete domestic tasks such as polishing and vacuuming. Each care plan had a background profile for each person. It was noted improvements were needed in ensuring there was additional information about service users preferences such as getting up and going to bed. It was noted the care plans had not been reviewed since July 2005 and had not been signed by the service user. Monthly up dates were completed by keyworkers, which included information as to healthcare checks Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 12 and activities they were involved in. The third care plan seen had a new format introduced by the manager which on examination was more of an assessment format rather than a care plan that sets out how care and support is to be delivered. However, the manager could consider using this assessment format in updating assessments for the other service users as part of the review process. The manager commented that she would be looking to access training in care planning for all staff. Risk assessments were in place for service users were in place showing how service users were to be supported in the community and in the home. It was noted one sampled was incomplete while another had not been signed or dated. One risk assessment relating to a service user leaving the building unescorted had not been reviewed or signed so it was not clear whether this was still relevant to the individual’s circumstances. Service users have weekly peer group meetings every Sunday where they can talk about future activities and choose the menu for the week. When walking round the building one service user stated she was involved in choosing the colour scheme for her bedroom, which had recently been decorated. Staff completed minutes of the meetings. One of the minutes referred to the service users choosing their forthcoming holiday to Blackpool. The manager has introduced a system where by each keyworker will complete a daily diary, which will provide evidence of activities requested by service that have been completed. These will be evaluated on a monthly basis ensuring staff have actually assisted service users to choose their preferred activities. Westbourne Care DS0000017002.V295206.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, 15, 16, 17 Quality outcome is good. Judgement has been made using available evidence including visit to service. Service users have access to leisure activities in the community, as well as organised activities provided by other agencies. The daily recording of service users still does not reflect how they spend their leisure time. Service users have no unnecessary restrictions subject to their individual risk assessments. The menus provide a range of nutritious meals offering service users a choice on a daily basis. EVIDENCE: During the course of this inspection a number of service users were out participating in activities provided by the local college and day services provided by the local authority. Those that were in the houses were spending time watching television in their bedroom. One service user showed his large jigsaw puzzle and spoke about his recent trip to the pub. He was going out later with to the local Bingo hall, which is located across the road from the service. Another service user who returned from his daycentre showed a picture frame he had made. His bedroom was decorated in the colours of his favourite football team Birmingham City. The service user stated he preferred to follow his team listening to the matches on the radio rather than go out and Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 14 watch them. The manager stated that the service users would be going to Blackpool later in the summer, which they were looking forward to a great deal. A sample of service users’ daily records referred to where service users had been out in the community pursuing leisure activities such as going to the cinema, bowling and a disco that occurs every Wednesday. An examination of the daily reports for the service users found some of the entries tended to be repetitive with phrases such as “appeared fine” and “chatted with staff”. This did not always reflect how they spent their leisure time. The recording did make some reference to where service users had been involved in domestic tasks such as making their bed, vacuuming and dusting their bedroom. Observations at the time of this inspection indicated the service users were not subjected to any unnecessary rules or routines. It was also observed that they had keys to their bedroom. It was also apparent there is a positive relationship between staff and service users. The group of service users in No 55 seem to get on very well as was noticed while they sat in the dining room waiting for their tea where there was a lot of conversation and laughter. A service user pointed to one member of staff to indicate that staff member was her favourite. A sample of three service users’ records found service users are able to maintain contact with their relatives. Two relatives spoken with at the time of this inspection stated that the manager would invite them to birthday parties even when it involved other service users. They spoke of how inclusive the staff and manager made them feel when they visited. There was evidence sampled on one service user’s care records that staff demonstrate sensitivity when supporting personal relationship between service users. Menus provided prior to this inspection indicated service users were receiving a choice of healthy meals. An examination of the food cupboards indicated there was fresh vegetables available and that the food was purchased from reputable suppliers. An examination of one service user’s record did refer to where they had been involved in preparing a pizza. This was confirmed when interviewing a member of staff who stated that some service users tended to be involved in preparing meals at the weekends and had also been involved in making cakes. It was observed some service users were able to make their own drink and could have one at any time of the day. Westbourne Care DS0000017002.V295206.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 outcome is good. Judgement has been made using available evidence including visit to service. Service users receive care and support that is flexible in meeting their personal care needs. Appropriate arrangements are in place for the management of service users’ healthcare requirements. Medication management is to a good standard promoting service users’ good health with some minor improvements needed. EVIDENCE: Three service users care records sampled indicated preferences with they managed their care. Daily recording of service users showed when service users had been supported or managed their own personal care such having a bath or shower. They would also refer to when service users chose to have a lie in at the weekends. At the time of this inspection a member of staff was observed to be asking a service user if he would like to have a wet shave or use his electric shaver before going out. The manager had addressed a requirement from the previous inspection for the development of manual handling assessments and three were seen confirming this. Due to the equal number of male and female service users presently accommodated the staff team does provide a balanced mix of male and female care staff on duty. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 16 Further examination of the care records confirmed service users had access to community healthcare support from professionals including a GP, Chiropodist, Optician and Dentist. Improvements had been made with the recording of service users’ weight. There was written evidence confirming each service user had been weighed every month. The manager had started work in developing individual health action plans for each service, which was a requirement from the previous inspection. It was good to see that the service users were involved in their development with photographs and drawings used. At the time of this inspection a visiting Community Nurse commented that staff were very co-operative and would follow up any issues that needed addressing. The Community Nurse had been providing consultation for staff about how to draw up individual health action plans. Medication management was found to be good although when examining the Medicines Administration Records for the previous month, two instances were seen where there were gaps in recording. However, the manager was committed in ensuring these errors would be addressed. She responded positively to a suggestion in undertaking a spot audit of staff administering medication and staff medication audit tool developed by the Commission’s Pharmacist Inspector was passed on following this inspection. A staff training matrix provided by the manager indicated that the majority of staff had completed accredited medication training. Westbourne Care DS0000017002.V295206.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 outcome is good. Judgement has been made using available evidence including visit to service. Service users have access to a complaints procedure that has accurate information about contacting the Commission. Service users welfare is adequately protected with the management working closely with other agencies to support vulnerable adults. EVIDENCE: Neither the service nor the Commission has received any complaints since the previous inspection. In conversation with one service user he stated that he would take any problems to the manager. Two members of staff interviewed were aware of the service’s complaints procedure and one even mentioned referring service users to the Commission if they had any complaints. The complaints procedure had been amended since the previous inspection with correct contact numbers for the local CSCI office. A photograph of the Inspector was on display outside the manager’s office. The manager provided information about a training session that was being organised for staff around the multi- agency guidelines published by Birmingham Social Care & Health. The manager has also made arrangements for staff to receive training in dealing with conflict and management at work. There is a policy and procedure in place for physical intervention. The manager provided two examples of service users personal allowance expenditure sheets that confirmed two signatures were in place when completing transactions. This addressed a requirement from the previous inspection. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 18 Two members of staff interviewed provided satisfactory responses to questions around adult protection and addressing poor practice. Since the previous inspection the service had made an adult protection referral to Birmingham Social Care and Health concerning the welfare of one of the service users who had recently moved from another service. There was documentary evidence confirming the service had maintained detailed records and there were minutes of reviews involving various professionals. There was evidence confirming the CSCI had been kept informed of events. Westbourne Care DS0000017002.V295206.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, 30 Quality outcome is good. Judgement has been made using available evidence including visit to service. Service users live in premises that is cleaned and maintained to an acceptable standard with improvements being made to provide a homely environment. Improvements have been made with regard to how staff maintains infection control practices promoting service users’ health and safety. EVIDENCE: The pre-inspection questionnaire stated that improvements had been made to the premises since the last inspection. The carpet on stairs in No 53 had been replaced due to wear and tear. New carpet had been fitted in the lounge at No 55, as had one of the bedrooms in the same property. A shared bedroom at No 55 had been re-decorated and as previously mentioned the service user was pleased to show the room and stated she had chosen the colour scheme with the person sharing the room. An order had been placed for the furniture in the lounge at No 53 to be re-upholstered. Repairs had been made to the kitchen cupboards in both properties. The manager stated that since the last inspection the owner had fitted temperature control valves for the shower units. A requirement for a crack on the ceiling to be repaired in a service user’s ensuite facility had been addressed. The manager also stated that the standing boilers in both dining areas would shortly be taken out and refitted in the Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 20 bathrooms on the first floor. This will mean the dining rooms will be redecorated and have new floor coverings. Both properties were clean, tidy and maintained to an acceptable standard. There were plastic aprons in the kitchen that were used by service users when preparing meals in the kitchen. Tabards had been purchased for staff. This addressed a requirement from the previous inspection to improve practices with regard to infection control. Westbourne Care DS0000017002.V295206.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): 31, 32, 33, 34, 35 Quality outcome is good. Judgement has been made based on available evidence including visit to service. Service users’ interests are protected with new staff being given current job descriptions informing them of their duties and responsibilities. Service users are supported by adequate numbers of staff on duty that have an understanding of the current group of service users. Staff receives appropriate levels of and training enabling them to undertake her duties effectively. Staff recruitment records meet the required standards protecting service users’ interests. EVIDENCE: Two members of staff were interviewed and were able to provide a good understanding around the needs of the current group of service users. Observations at the time of inspection indicated service users were comfortable in the presence of staff with their routines respected and known. A number of staff records were examined for two new members of staff. There was evidence of proof of identification including a passport and photo, CRB check, job application form, contract and two references. Since the last inspection the manager has included current job descriptions with the staff files, which, was a requirement from the previous inspection. There was evidence seen that updated contracts had been completed for current staff. It was noted however that the staff files for newly recruited staff did not have a record of the interview and discussion with the manager identified the need for Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 22 an interview assessment format ensuring there is evidence confirming the suitability/unsuitability of the prospective employee. The staff recruitment procedure had been amended to include information about CRB and POVA checks. The pre-inspection questionnaire stated that excluding the manager eighteen staff had NVQ Level 2 or above which is well over 50 of the workforce. Staff’s NVQ certificates were on display in the office. Staff had also completed training in the Learning Disability Award Framework or LDAF, as it is known. This was confirmed when talking to two members of staff and when examining a staff training matrix, which the manager had developed since the last inspection. There was evidence confirming staff had completed the majority of mandatory training topics including first aid, fire safety, manual handling and infection control. A number of staff were completing updated infection control training. It was noted a number of staff were due updated training in food hygiene. Comments were made to the manager in ensuring that the matrix including other areas such as adult protection and other subjects such as for example autism awareness and epilepsy. However, the development of the training record matrix shows a much, improved method of record keeping in this area. Standard 36 was not assessed in depth but two staff stated they had recent one to one supervision with the manager and there was a supervision schedule seen in the office indicating staff had received supervision twice since January 2006. The manager stated that they had linked up with a representative from Birmingham Chamber of Commerce to provide training in developing staff appraisals. An examination of the pre-inspection questionnaire stated two members of staff had left since the previous inspection both for personal commitments. At the time of this inspection the levels of staff on duty appeared to meet the needs of the current group of service users. There were three staff on duty during the evening including a senior carer. There is one sleep in and one night waking member of staff. An examination of the staff rota for the previous four weeks provided clear information as to the duration of the shifts worked by the staff and manager, including, who was off duty. Westbourne Care DS0000017002.V295206.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): 37, 39, 41, 42 The quality outcome is good. This judgement has been based on available evidence including visit to the service. Service users are supported by a manager by a competent manager committed to improving the quality of the service. Service users are given opportunities to comment on the management of the service. Service users’ health and safety is promoted and maintained with minor improvements needed. The records were generally up to date protecting service users’ interests. EVIDENCE: Since the previous inspection the deputy manager was successful in achieving registration as Registered Manager for the service with the Commission. The manager is qualified to the Registered Managers Award. It was evident that the manager had worked hard in addressing the requirements from the previous inspection. Comments and suggestions were received positively. It was noted that the service had achieved an award with Solihull College for Employer of The Year for its commitment to staff training and development. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 24 There was evidence available confirming the Registered Provider visits the service every month and reports for these were available for inspection with comments from service users and staff about how the service is being managed. Since the last inspection the manager had developed anonymous satisfaction questionnaires for service users, relatives, staff and professionals involved in the service users’ care. These were being sent out at the time of this visit. The atmosphere at the time of this inspection was relaxed and friendly. Two members of staff spoke of positive working relationships and that the manager was always available for advice and support. It was evident from observations that service users were able to approach the manager for advice or just to have a chat with time being allowed by the manager to talk about how their day had been. At the time of this inspection the manager was undertaking a review of the polices and procedures ensuring these were reflecting current practice. Records held on the premises were up to date and stored in a secure facility. Health and safety records were seen to be satisfactory. There was evidence that the fire alarms were being tested every week. The emergency lighting had been tested every month, which was a requirement from the previous inspection. There was evidence confirming staff had received fire training since the last inspection but a fire drill was overdue. A risk assessment for the prevention of fire was in place. A daily temperature records were being maintained for the refrigerators and freezers but it was noted some of the readings noted indicated the minimum/maximum temperatures were too extreme. The manager stated she would check that the thermometers were working effectively. An examination of the accident book found there had been no accidents since the last inspection. Improvements had been made with regard to notifying the CSCI of incidents affecting the welfare of service users via Regulation 37. Westbourne Care DS0000017002.V295206.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 3 2 N/A 3 3 4 N/A 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 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 2 35 2 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 N/A LIFESTYLES Standard No Score 11 N/A 12 2 13 3 14 N/A 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 N/A 3 N/A 3 2 N/A Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1)(2) Requirement The Registered Person must ensure service users’ care plans clearly state how the needs of service users are to be met including their leisure interests. They must also be reviewed regularly. The care plans must have signatures of service users confirming involvement in their development. Outstanding Requirement. Timescale 29 January 2006 not met. The Registered Person must ensure all risk assessments pertaining to service users are reviewed and updated to reflect current circumstances. The Registered Person must ensure the daily recording of service users reflect how they spent their leisure time. Outstanding Requirement. Timescale 29 January 2006 not met. The Registered Person must ensure fire drills occur every six months. Timescale for action 16/07/06 2. YA9 13(4) 16/07/06 3. YA13 12(2)(3) 16/06/06 4. YA42 13(4) 23(4)(e) 16/06/06 Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 27 5. YA34 17(2) Sch 2 The Registered Person must ensure it develops an interview assessment tool to be used as a record of the interview process and for feedback to prospective employees. 16/07/06 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 YA30 YA20 Good Practice Recommendations It is recommended that when the current washing machine comes to the end of its working life that the Registered Person replaces it with one that has a sluice programme. It is recommended that the Registered Person undertakes a medication audit to assess staff competency in administering medication to service users. Westbourne Care DS0000017002.V295206.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Westbourne Care DS0000017002.V295206.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. 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