Inspection on 29/11/05 for Westbourne Care

This inspection was carried out on 29th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 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 16/05/06

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 29th November 2005 11:00 Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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.V266331.R01.S.doc Version 5.0 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.V266331.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Westbourne Care Address 53/55 Stockfield Road Acocks Green Birmingham West Midlands B27 6AR 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 Ms Sandra Mann Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 23rd May 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.V266331.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day. The Inspector had the opportunity to talk to three service users and two members of staff and the deputy manager. Care practices were observed including interactions from staff. A tour of the premises was inspected. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined and a number of health and safety records were also sampled. What the service does well: Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not distinguishable. Service users were observed to receive friendly and professional support from care staff. At the time of this inspection the atmosphere was friendly and relaxed with the service users looking forward to Christmas and their party that was taking place two days after the inspection. One service user stated she had helped staff make the Christmas decorations for the tree in their lounge. Two service users who share a room were very pleased with a new TV set that had been donated by a relative of their friend who recently died. Another service user was pleased to state how independent she was and went out on public transport to college. She also had her own coffee making facilities and a computer and was due to have her own website. Service users are encouraged to maintain their independence and two were observed to make their own drinks. The daily recording of service users showed they were also involved in tidying their bedrooms and doing the laundry. The service users had gone on holiday to Great Yarmouth, which they enjoyed a great deal. During this inspection two service users had gone out to the local Bingo hall. The service users are also able to access activities such as bowling, cinema and go out for meals. Service users have access to cable television and when looking around both properties it was evident the bedrooms are personalised to their own lifestyle and each service user has a key to their bedroom. An examination of service users records confirmed that the manager was making sure they were being seen by a GP, chiropodist, optician and dentist. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: While there have been improvements since the last inspection there are still some outstanding requirements which the manager must take action to address. An examination of staff training records indicated that not all staff had received up to date training for first aid and manual handling. The training records were not up to date and there were names of staff that had long left the service but their records had not been removed. The manager must ensure all staff training records are up to date. Training in adult protection and physical intervention had not been undertaken since the last inspection. Not all the staff records examined had a current job description and contract. When looking through the health and safety records it was found the testing of the emergency lighting was not completed every month. Care plans for the service users must state more clearly how the needs of the service users are to be met particularly with regard to their leisure interests. An examination of the accident book found that while there were only five accidents in total for both properties, these had not been reported to the Commission. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 7 Individual Health Action Plans will need to be developed for each service user so there is information available about how their healthcare needs should be addressed. 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.V266331.R01.S.doc Version 5.0 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.V266331.R01.S.doc Version 5.0 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, 2, 3, 4, 5 The Statement of Purpose is in need of amending so that prospective service users can make an informed decision about where they live. Service users needs are currently met with service users who are well cared for by supportive and friendly staff. Service users have a written statement of terms and conditions, which will need some amending to include any costs for transport. EVIDENCE: The service has a Statement of Purpose, which was found to require some amendments. It must state nursing care is not provided. The section on complaints must include contact details of the CSCI and state the CSCI can be contacted at anytime. The Statement of Purpose must also include the sizes of the bedrooms. It must also make clear that the premises is not accessible for wheelchair users. The section on the arrangements for care planning must say how often service users’ care plans are to be reviewed with reference to the requirements of the National Minimum Standards. An examination of two service users records indicated that each one has a contract. These will need amending to include information whether service users have to contribute towards any transport costs and that this should come from their Disability Living Allowance Mobility Component. At the time of this inspection a new service user was currently being introduced to the service from another care home. There was documented Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 10 evidence demonstrating when the prospective service user had teatime visits and overnight stays. There was information from the other service that had basic details of the service user’s needs. However, there was no evidence of an assessment and initial care plan from a social worker. The Statement of Purpose has an admission criteria. Service users needs were met at the time of inspection. The service users were looking forward to Christmas and two said they had helped to make the decorations for the tree and were looking forward to their Christmas party. One service user said she was independent and travelled by herself to college on public transport. The service users were dressed appropriately for the climate of the day. Staff were observed to provide positive and friendly support. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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, 8, 9 Care plans require improvements in stating how the needs of service users are to be met particularly with regard to their leisure interests. Service users are encouraged to make decisions about their lives through the use of peer group meetings, but the minutes for these must provide more evidence as to how individual choices were made. Service users have risk assessments concerning limitations on their independence in the home and in the community. EVIDENCE: An examination of service users care plans found each service user had a pen picture of their past history. While the care plans covered most aspects of their daily living activities some improvements were required. There was no specific information regarding service users leisure interests. For example one service user stated she was dedicated fan of the rock group Queen and had lots of their CD’s. This was not fully reflected in her care plan nor what kind of subjects she did at college. Two care plans examined had monthly reviews completed by the service users’ keyworker, although one was found to have had a monthly review since September 2005. There were also statements stating “supervision required” but with no information how this should be carried out. The deputy manager stated that she was going to contact a representative from Birmingham Social Care & Health ‘s Person Centred Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 12 Planning Co-ordinator for guidance around developing person centred plans for each service user. Risk assessments were in place for service users including going out in the community and for undertaking tasks in the kitchen. The risk assessments had been reviewed since the last inspection. Service users have weekly peer group meetings where they can talk about future activities and organise the menu for the week. The minutes for these will need to provide more evidence as to how the service users are expressing their preferences with regard to future activities and evidence where staff are informing service users of the complaints procedure and who they can contact if they have any concerns. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 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 do not reflect how they spend their leisure time. Service users have no unnecessary restrictions subject to their individual risk assessments. EVIDENCE: At the time 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. Two service users had gone out to the local Bingo hall with a member of staff and spoke of how much they enjoyed it. Another service user stated she went to college learning how to use a computer and enjoyed doing artwork. The service user had her own computer and was pleased that she was going to have her own web site address. An examination of service users records found they had been involved in activities such as bowling, going out to the cinema and for pub lunches. One service user’s care plan referred to a local church that he visits every Sunday. It was good to see service users were able to maintain their independence. One service user has her own coffee making facilities and travels Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 14 independently by public transport. Daily recording of service users referred to where they had tided their bedroom or had done their laundry. Two service users stated they had a key to their bedroom. It was noted the daily recording of service users did not always reflect how service users spent their leisure time. For example some entries referred to service users watching TV or listening to music but without any reference whether these were of their own choice of music or programme. All the service users had participated in a holiday to Great Yarmouth earlier in the year. There were also trips out in the summer including to Drayton Manor Park. Observations at the time of this inspection it was evident service users were not subjected to any unnecessary rules or routines subject to individual risk assessments. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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 Service users care is flexible and supports their individual needs. Service users healthcare is appropriately managed by staff promoting good health, but improvements are required with monitoring their weight. Medication management has improved since the last inspection maintaining service users’ good health. Not all service users have manual handling assessments that identify individual requirements. EVIDENCE: A sample of service users records documented their preferences with how they maintained their personal care. There was evidence confirming service users’ contact with community healthcare services including a GP, optician, dentist and Chiropodist. Evidence was also seen of a number of service users who had medication reviews with a consultant psychiatrist. One service user was receiving regular appointments with a psychologist. An examination of one service user’s care plan identified concerns that their increase in weight was affecting their mobility but the service user was not being weighed every month. There was no action plan to confirm how the service user’s weight was to be reduced. Discussion with the deputy manager identified the need for each service user to have their own Health Action Plan within the spirit of the Department of Health’s Valuing People White paper. It was noted that not all service users records had manual handling Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 16 assessments and these must be in place even for those service users who do not have any manual handling requirements. Two service users stated they were able to get up and go to bed when they wanted to and there was evidence seen on the daily records that service users would choose when to have a lie in at the weekend. The daily recording also referred to where service users had received assistance with their personal care. Medication management was found to be good and the manager had addressed a requirement from the previous inspection for a list of trained staff signatures that administer medication. Another requirement addressed was for the Medicines Administration Records or MAR charts as they are known to indicate where medication is being carried over the from the previous four week cycle. It was noted that a handwritten entry on the MAR sheet for a service user to take paracetamol did not have the strength and dosage completed and care should be taken with this. Photocopies of prescriptions were attached to the MAR sheets. There were written protocols in place for the administration of PRN medication. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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 Service users have access to a complaints procedure, but it has incorrect contact details for the Commission. Service users welfare is protected but the prevention of abuse training for vulnerable adults must be undertaken. There is an adult protection policy and procedure that needs amending to reflect the Department of Health’s Guidance No Secrets. EVIDENCE: Neither the provider nor the CSCI have received any complaints since the last inspection. It was noted that the complaints procedure was available in the service users’ bedrooms. However, the telephone contact numbers for the CSCI was incorrect and the manager must ensure this is addressed. Two members of staff interviewed provided satisfactory responses to questions with regard to protecting service users from abuse and how they would deal with any complaints made by service users. A requirement for staff to have training in the protection in the abuse of vulnerable adults had not been addressed nor for physical intervention. The deputy manager stated that those staff that had completed training in the Learning Disability Award Framework had completed a module on abuse. While this is acknowledged it is expected that training in adult protection should be included as part of the service’s mandatory training programme. There is an up to date copy of the Multi Agency Guidelines for adult protection published by Birmingham Social Care & Health. An adult protection policy and procedure is in place but some amendments are required to include reference to the Multi Agency Guidelines and an outline of training available to staff. It must include information on organisations that provide support. There is no policy and procedure for physical intervention. Service users personal allowances were examined. There was an individual record of monies coming in and for what purpose with a final balance. Monies Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 18 are held individually and those checked were correct and corresponded with the final balances. There was evidence of receipts for expenditures. It was noted that two signatures were not always in place when completing transactions. There was information regarding each service user’s benefit entitlements and all the service users have their own bank accounts. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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, 26, 27, 28, 30 The premises are maintained to an acceptable standard and provide a clean, safe environment for service users with some minor improvements required. Some improvements are required with regard to how staff maintains infection control practices. Service users have access to comfortable communal space that is comfortable and homely. Service users bedrooms are individually personalised to their own lifestyle and tastes. Service users have access to suitable bathing and toilet facilities that currently meet their needs. EVIDENCE: A tour of both properties was undertaken and these were found to be generally clean, tidy and well maintained. The weather outside at the time of this inspection was very cold but both properties however, were warm including the service users bedrooms. However, it was noted in one service user’s bedroom that the en-suite shower cubicle had a large crack on the ceiling and the extractor fan was in need of cleaning. Observations at the time of this inspection noted staff were not wearing protective clothing while preparing food. There is a separate laundry facility with two washing machines and a tumble dryer. It was noted that one of the washing machines had recently been replaced. The Registered Provider must be mindful when the current equipment is at the end of its working life a washing machine with a sluice programme is installed as stated in Standard 30. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 20 Service users bedrooms were found to be individually personalised and it was evident they had their own possessions including photographs, TV, stereo systems and video recorder and DVD player. All the service users have access to cable television. It was noted one service user’s bedroom had their bed against an uncovered radiator. The manager must ensure this is covered to reduce the risk of scalding. Two service users who share a room were very pleased with a new TV set that had been donated by a family member of a past service user who used to live with them and had recently died. One of the service users pointed to his wide collection of DVD’s including the Inspector Morse TV series which he enjoys watching. Another service user had his bedroom decorated in the colours of his favourite football team Birmingham City. Both properties have comfortable lounges providing a homely setting. There are separate dining areas in both premises and service users have access to both kitchens. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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 Not all new staff have job descriptions to inform them of their duties and responsibilities of working with the current group of service users. Staff rotas do not clearly state the hours worked by staff. Service users are supported by staff that have an understanding of the current group of service users. Recruitment records have improved since the last inspection, protecting the interests of service users. The staff recruitment procedure does not reflect current practice and the requirements of the National Minimum Standards. Training is offered to all staff employed to enhance their development but the records for staff training need to be up to date ensuring all staff have received mandatory training. EVIDENCE: Two members of staff recently recruited to the service were able to provide a good understanding around the needs of the current group of service users. Service users’ needs were known and respected. A number of staff recruitment records were examined including those for newly employed staff. There was evidence to confirm that the manager had addressed a requirement from the previous inspection for confirmation of staff CRB checks to be available on individual staff files. There was a list of existing staff with their CRB disclosure numbers and for new staff copies of their CRB disclosures. There was also evidence confirming that new staff had completed medical questionnaires regarding their fitness for employment. This was also a Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 22 requirement from the previous inspection. Among the documentation seen were job application forms, two references proof of identity including photograph, passport and birth certificate. It was noted not all staff had contracts and current job descriptions. An examination of the training records found that a number of staff were due updates for mandatory training in first aid and manual handling. The staff training records provided by the deputy manager were in need of updating as the records contained information about staff who had long left the service but this had not been indicated clearly. A training matrix must developed that identifies future training needs for all staff and where updated training is required in mandatory topics. There was evidence new staff had a record of their induction. There were certificates on display showing that four members of staff had completed foundation training towards the Learning Disability Award Framework. There were also certificates on display confirming that four members of staff had qualified to NVQ Level 2 and one who had NVQ level 3. The deputy manager stated that since the last inspection two members of staff had left the service and two had been recruited since the last inspection. One however, was on currently on compassionate leave. The levels of staffing appeared to meet the needs of the current group of service users. In discussion with the deputy manager she stated there were three staff on duty during the day and evening including a senior staff member. There is one sleep in and one night waking member of staff. However a copy of the staff rota for the previous four weeks did not provide clear information as to the duration of the shifts worked by staff and the manager. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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, 38, 39, 41, 42 Service users live in a home that is run by a competent management team. Service users and staff are able to raise any concerns with the management in an open relaxed atmosphere. Service users and staff do not have sufficient opportunity to comment on the management of the service. Improvements are needed with regard to the maintenance of its records that are out of date. Service users’ health and safety is promoted and maintained but a number of improvements are required. EVIDENCE: The deputy manager was present during this inspection and was able to provide a good understanding around the needs of the service users in her care. Comments and suggestions made were received positively and she acknowledged there was still work to do in addressing the outstanding requirements in this report. She has made an application to the Commission for to be the Registered Manager. The atmosphere at the time of this inspection was relaxed and friendly which the service users appreciate. Two service users and staff members stated they would be able to approach the deputy manager if there were any concerns and for guidance. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 24 There was some evidence available to confirm that the Registered Provider visits the service but it was noted these visits did not occur on a monthly basis. The reports for these did not provide evidence that the views of service users and staff about the management of the service were not being sought. Discussion with the deputy manager identified the need for the development of an annual quality assurance system. Records held on the premises were to a certain extant up to date and stored in a secure facility. However, when examining service the personal allowances for service users there was a lot of receipts from over a year ago among the current receipts and the manager must ensure these are suitably archived an ensure easy tracking of information. Records with regard to health and safety were found to require improvement. There was evidence that the fire alarms had been tested every week. However, there was evidence that the emergency lighting had not been tested every month. Staff had received fire training and participated in a drill prior to this inspection. Equipment for the prevention of fire had been completed since the last inspection. A portable appliance check had also occurred since prior to this inspection. A requirement for the prevention of fire risk assessment to be reviewed had been addressed. The accident book was examined and it was noted there were a total of five accidents since the last inspection. However, these had not been reported to the CSCI via Regulation 37 notification. The deputy manager stated that since the last inspection an Environmental Health Officer had made a visit, and two requirements had been issued. The deputy manager showed which requirements had been addressed including a brush to be fitted to the bottom of the food storage cupboard door. At the time of publication of this report a copy of the Environmental Health Officer’s report was forwarded to the Commission. A daily record was being maintained for the temperatures of the freezers that was a requirement from the previous inspection. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 N/A Standard No 24 25 26 27 28 29 30 STAFFING Score 3 N/A 2 3 3 N/A 2 LIFESTYLES Standard No Score 11 N/A 12 2 13 3 14 3 15 N/A 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 2 2 2 N/A CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Westbourne Care Score 2 2 3 N/A Standard No 37 38 39 40 41 42 43 Score 3 3 2 N/A 2 2 N/A DS0000017002.V266331.R01.S.doc Version 5.0 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 YA1 Regulation 4(1a-c) Sch 1 Requirement The Registered Person must ensure the Statement of Purpose is amended to include the following: Timescale for action 29/01/06 2. YA2 14(1) 3. YA5 5(1)(b) Nursing care is not provided. Sizes of the rooms. The frequency of service users’ plans reviews. Contact details of the local CSCI office and that they can be approached at anytime during the complaint process. Where the service does not meet the environmental standards e.g. premises unsuitable for wheelchair users. The Registered Person must 29/01/06 ensure prospective service users are only admitted to the service following a needs led assessment and initial care plan completed by a Social Worker. The Registered Person must 29/01/06 ensure individual service users’ contracts state whether service users are expected to contribute towards any transport costs. DS0000017002.V266331.R01.S.doc Version 5.0 Page 27 Westbourne Care 4. YA6 15(1)(2) 5. YA8 12(3) 6. YA12 12(3) 7. YA18 13(5) 8. YA19 12(1a,b) (2) 9. YA19 12(2) 10. YA23 13(7) 18(1a,c) 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 Registered Person must ensure service users’ peer group meetings provide more evidence of how service users have made decisions regarding their activities and menus The Registered Person must ensure the daily recording of service users reflect how service users spend their leisure time. The Registered Person must ensure all service user have up to date manual handling assessments. They must also be completed for those who do not have any movement and handling requirements to confirm this. The Registered Person must ensure service users have an individual Health Action Plan in line with the Department of Health’s Valuing People Guidelines. The Registered Person must ensure service users weight is recorded every month. Any reasons why this has not been done must be documented. Service users care plans must document how any specific healthcare issues including dietary needs should be managed. The Registered Person must ensure all staff receives training in adult protection and physical intervention. Outstanding Requirement. Timescale 23 August 2005 not met. DS0000017002.V266331.R01.S.doc 29/01/06 29/01/06 29/01/06 29/01/06 28/02/06 29/01/06 29/01/06 Westbourne Care Version 5.0 Page 28 11. YA23 13(6) The Registered Person must ensure all transactions involving service users’ personal allowances are accompanied by two signatures. The Registered Person must ensure the adult protection policy and procedure is amended to include reference to the Local Authority’s Multi Agency Guidelines. It must also outline training available to staff and provide a list of organisations that provide support. The Registered Person must ensure the crack on the ceiling in the en-suite bathroom in the service user’s bedroom is repaired. The extractor fan is in need of cleaning. The Registered Person must ensure the unguarded radiator in the identified service user’s bedroom is covered as the bed is against it and there is a risk of scalding to the service user. The Registered Person must ensure all staff preparing food in the kitchen wear protective clothing. The Registered Person must ensure all staff recruitment records include a current job description and statements of terms and conditions. The Registered Person must ensure that it develops an up to date staff training matrix that identifies individual training requirements. Any gaps in mandatory training updates in first aid and manual handling must be addressed. 29/12/05 12. YA23 13(6) 29/01/06 13. A24 23(2)(b) 29/12/05 14. YA26 13(4) 29/12/05 15. YA30 13(3) 29/11/05 16. YA34YA31 Sch 2 29/01/06 17. YA35 18(1a,c) 28/02/06 Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 29 18. YA39 26(1)(2)(a- The Registered Person must ensure that visits to the service c) 3 must be undertaken every month. Reports for these visits must provide evidence where service users and staff have commented on the management of the service. 24(1)(a)(b) The Registered Person must ensure it develops a means of annually reviewing the service preferably through a professionally recognised Quality Assurance system based on seeking the views of service users, staff relatives and professionals involved the treatment and care of the service users. This must include the development of anonymous satisfaction questionnaires. 17(2) The Registered Person must ensure service users’ receipts are stored more appropriately. Training records for staff that have left the service must be removed and are up to date. 13(4) The Registered Person must 23(4)(c)(v) ensure the emergency lighting is tested every month. 13(4) The Registered Person must 37(1)(e)(f) ensure any incident affecting the welfare of service users and any accident in the care home is reported to the CSCI without delay. Outstanding Requirement. Timescale 23 May 2005 not met. 28/02/06 19. YA39 29/03/06 20. YA41 29/01/06 21. 22. YA42 YA42 29/12/05 29/11/05 Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 30 23. YA33 18(1) The Registered Person must ensure the staff rota contains the following information: Person in charge. Designation of post. Hours worked. Handovers. Must include record whether rota worked. 29/01/06 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. Refer to Standard YA30 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. Westbourne Care DS0000017002.V266331.R01.S.doc Version 5.0 Page 31 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. 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