Inspection on 05/04/07 for Westbourne Care

This inspection was carried out on 5th April 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westbourne Care 16/05/06

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 Kath Strong Key Unannounced Inspection 5th April 2007 09:00 05/04/07 Westbourne Care DS0000017002.V334965.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.V334965.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.V334965.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 lorraine28@blueyonder.co.uk 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.V334965.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 16th May 2006 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, the home does not have a shaft lift between floors. Therefore the Registered Provider must remain vigilant to the possibility of increasing physical and sensory needs of service users in the future. The current fee rate was £679.47 per week for all service users. This did not include the costs for Chiropody, hairdressing, transport, clothes or meals out. When all service users go out for an activity the home subsidises the expenses for this. Westbourne Care DS0000017002.V334965.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 with a number of residents and some staff. The registered manager provided assistance throughout the visit. The arrangements for healthcare, personal care and activities of daily living were reviewed. Relevant documentation was checked including three care plans. Health and safety and the system for medications were reviewed. The communal areas and a number of bedrooms were visited. Staff personal records were checked as well the training that they have undertaken. At the conclusion verbal feedback was given the registered manager. What the service does well: The external features of the premises are consistent in design with other neighbouring buildings in that they give the appearance of being a house. This promotes the homely, non-institutional environment for the benefit of those people residing at the home. The staff have developed various and effective means of communicating with residents to ensure their understanding and rights whilst living at the home. As with previous inspections staff make all efforts in maintaining residents health and well being and they are supported in achieving this by the services of a range of external professionals. Residents are encouraged and supported in making choices about how they wish to live. Some attend college or day centres and there is ample evidence of in-house and external activities that are tailored to individuals’ preferences. There were no obvious restrictions observed on residents daily activities, staff were observed actively encouraging a relaxed and friendly lifestyle. This practice ensures that residents control their own lives. Relatives and friends are routinely invited to birthday celebrations and the Christmas party. Personal relationships with families and friends are encouraged to promote continued relationships. Staff knowledge of residents needs ensures that they enjoy a quality lifestyle and opportunities are offered. Residents choose where they wish to go for their main annual holiday to ensure that they experience maximum pleasure from the event. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 7 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.V334965.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and five. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home needs to comply with its current registration by applying for a variation for the older residents. The home gathers preadmission information from various sources and carries out its own assessment to ensure that it is able to meet the individual’s needs. The contract of terms of residency advises of what is paid for in the fee rate and additional charges. EVIDENCE: A copy of the last report was on display in the reception area for people to read at their leisure. It was noted that one resident is above the age of 65 years of age and another will be 65 in December of this year. The home needs to monitor the health and mobility needs of those persons and against the services provided. The home is fully occupied and has not had an admission for a protracted period of time. There is a written admission policy for staff to follow and the manager described the process. A number of visits would be arranged at varying times of the day to give the prospective resident an overview of the home and those people who already live there. The manager would carry out an assessment and obtain relevant information from other professionals to assist in determining the needs and if the home can meet them. A placement Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 9 will not be offered if there are some needs that the home cannot meet. Following admission the home offers a 28 day trial period at the end of which a review is carried out by both parties before a placement is confirmed. The contract of terms of residency include which service are not included in the fee rate and care plans include a full breakdown of all incomes received by residents so that they have sufficient information about their rights. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about the way they wish to live and staff enable them in achieving objectives in respect of activities and activities of daily living skills. Risk assessments are developed and regularly reviewed covering respective activities to minimise the risk of injuries to residents. EVIDENCE: Each resident has a written care plan. This identifies the assessments carried out and the care that staff need to deliver to promote residents health, well being and type of lifestyle they wish to lead. Three residents care plans were sampled and reviewed. They included information about their background, life history, food preferences, social interests, hobbies and religious and cultural needs. This enables the home to develop care plans that are tailored to individual needs and some preferences of activities of daily living. Each file includes details such as attendance at day centres, literacy skills and means of communications. One resident uses signs and symbols to aid communications Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 11 another uses Makaton and teaches others including staff on use of Makaton. Residents are encouraged to carry out domestic tasks such as maintaining their bedroom, dusting and vacuuming. Risk assessments were found for all activities undertaken and had been regularly reviewed to ensure that risks were minimised as far as practically possible for protection of residents from injury. Key workers complete a monthly update and include information about the residents satisfaction with the support provided for them. Residents are encouraged and supported in assisting staff in preparing meals, one resident regularly makes refreshments for others and staff. Residents made positive comments about the services they receive, “I like everything, I bought my own socks, I like all sorts of things about the home”. Encouragement and support supplied by staff was observed to be positive and all residents were given an Easter card. A resident who had a history of not communicating well has continued to improve since the medications were withdrawn. It was evident that one resident is a keen football supporter and staff enable him to go to matches. Residents hold a weekly joint meeting where they choose activities that may not be on their programme. Staff make the necessary arrangements for the request to be fulfilled. The food menu for the following week is also agreed during the meeting. Residents are asked about there preferences for the annual holiday. One resident will be spending it in a hotel in Stratford and the remaining residents expressed a wish to go to Blackpool. A daily diary is maintained by staff, which provides information about the various activities that each resident has participated in. Following the joint meeting a private meeting is held by residents with their key worker to give them the opportunity to discuss topics in private. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents requests and choices regarding activities are supported and organised by staff, this promotes individuality and independence. There are no obvious restrictions imposed on residents in respect of daily routines. A wholesome and varied diet is offered and individual requests are catered for. EVIDENCE: During the course of this inspection a number of residents were out participating in activities and attending local colleges and day centres. The inspector spent some time talking with a resident who had packed her suitcase and was waiting to be collected by a relative to spend the Easter break with him. The manager said that the resident stays with the relative every four weeks. Another resident receives visits from a family member regularly. Where appropriate staff had made recordings about resident’s sexuality and relationships with families and friends. The home had booked a table for a meal out during the Easter time, Easter eggs had been purchased and a card was given to each resident during the inspection. The Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 13 home has booked to attend an ice skating show. Two residents go swimming every week. One resident has a large collection of soft toys, he said, “I’ve got loads of bears”. Residents enjoy going to an evening disco, to pubs and the nearby bingo hall. There was evidence of a good supply of indoor activities such as board games and videos/DVD’s and a number of residents were spending time in the garden with staff in attendance. Observations indicated a happy atmosphere with no restrictions imposed on residents. It was also noted that residents appeared to get on well with each other, there was plenty of conversation and laughter during the visit. Residents had been supplied with a key to their bedrooms. Residents were observed freely entering the managers office on a number of occasions and upon request one residents was supplied with shampoo and shower gel. Advice was given that residents celebrate birthdays and Christmas with parties with family and friends invited. This helps residents in maintaining family links and friendships. The home has a file containing procedures about diversity such as religious words in a number of languages, information about various religions and cultural awareness. The home has a file regarding Makaton, this is a way of communicating by use of language. There was a copy of the Code of Practice presented in Braille. These are considered to be a useful tool in assisting staff in understanding residents personal needs and how they can be met. During the peer group meetings held each Sunday residents negotiate and agree the food menu for the following week. To assist them in making appropriate choices meals are shown in pictorial format, these suggestions are of healthy foods. Staff record what each residents has eaten for breakfast, lunch and the evening meal. This indicated a varied and interesting diet is offered and the recordings confirmed that individual choices are catered for. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents healthcare needs are being met and monitored as required. Staff practices in respect of recordings for administration of medications needs some improvements. Observations of staff indicated that residents privacy and dignity are being maintained. EVIDENCE: Care plans include a dedicated section for recording of healthcare needs, medical history, dietary needs and monitoring of peoples weight. The files seen included good details such as inability to feel hot and cold which raises queries about ability to feel pain, allergies, slow reaction when issues of health and safety are involved. Personal hygiene needs and specific disorders are well documented. A resident who has been experiencing a higher rate of seizures was being investigated and well person health checks. Telephone calls with professionals are recorded and there was evidence of the involvement of a range of external professionals. The mechanism in place indicated that residents health and well being was being promoted. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 15 Moving and handling assessments and risk assessments had been developed and were being regularly reviewed. These included trip hazards for a resident. The home has an equal number of male and female residents and the gender of the staff team is balanced to ensure that all personal needs of residents were being appropriately and sensitively provided. The home was in the process of developing passports for healthcare but had not fully completed the initiative. The system for receiving, storage and disposal of medications were found to be good. The home has a chart for documenting which medications are taken out to be administered later in the day. The medications were being periodically checked. However there were occasions when staff were failing to enter on the MAR (medication administration record) chart whether or not the medication had been administered. This shortfall was identified at the last inspection of 16th May 2006 and therefore needs addressing. Only staff who have received accredited training are permitted to administer medications. Although no formal training has been provided, all have received talks in respect of caring for ageing persons. It is recommended that training in this aspect of care be considered as the home has one and will later this year have two residents in excess of the age 65 years of age. This enables staff to provide appropriate care for that age group. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents understand their right regarding complaints. The welfare of residents is adequately protected by the management of adult protection and financial transactions of residents personal monies. EVIDENCE: Neither the service nor the Commission has received any complaints since the last inspection of May 2006 or the previous inspection. The written complaint procedure is on display in the reception area of the home, the document needs to be further developed to include the timescale for resolution of complaints received. The procedure is also available in pictorial format to assist residents in understanding their rights. The document is very comprehensive and a copy of this is in each bedroom for ease of access. The written adult protection policy is also available in pictorial format to ensure residents understanding in this aspect. It clearly describes residents rights and what is unacceptable. There is a separate folder with further information on adult protection to enhance staff knowledge regarding their roles and responsibilities. A member of staff demonstrated good knowledge on how to respond to abuse and allegations of abuse. The home has recently introduced a policy of obtaining two staff signatures even though the resident may have signed in respect of financial transactions Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 17 of their personal monies. The manager reported that although residents sign they may not fully understand what they are signing for. This is viewed as being good practice in prevention of financial abuse. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in accommodation that is hygienic, well maintained and homely. Staff practices regarding cleanliness promote maintenance of resident’s health and safety. EVIDENCE: The premises consist of two converted house that have been linked. Each property has its own lounge, dining room, kitchen, bathroom and bedrooms. Although female residents live in one property and male in the other they are encouraged to mix and make use of the communal rooms. Improvements to the building since the last inspection include: • Removal of the boilers from the dining rooms, these have been rehouse in the laundry room • A new lounge suite has been purchased • The dining suite in one room has been replaced • A new more up to date television has been supplied Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 19 Both dining rooms have been redecorated and the new light fittings improve the standard of lighting • A resident has been provided with a new bed and armchair both of which are remote controlled • The ground floor toilets have been redecorated • A tumble dryer has been purchased for the laundry room. These improvements enhance the appearance of the home and the standard of facilities are enhanced for the benefit of residents. The bedrooms of those persons whose care plans were seen were visited and it was noted that they have been personalised to the extent preferred by the occupants. Rooms were very individualised. Both properties were clean, tidy and maintained to an acceptable standard. The kitchens were found to by hygienic and residents are asked to wear a plastic apron when helping staff to prepare meals. This practice prevents to control the occurrence of infections. • Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 37. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are maintained in sufficient numbers ensuring that residents’ needs are being met. Recruitment practices are robust and protect residents from harm. Staff training supplies them with the knowledge and skills to carry out their roles effectively. EVIDENCE: The home enjoys a low staff turnover; this helps to ensure consistency of care. The staffing rota of the previous six weeks indicated that staffing levels at all times are consist and meet the needs of the current client group. The home needs to monitor any developing needs of the older residents and take appropriate action where concerns are evidenced in respect of healthcare and staffing levels to match needs. Residents appeared to be comfortable and confident with the staff on duty and resident’s routines were known and respected. Examination of staff records indicated that the necessary checks are carried out and references sought before an applicant is offered a position. This indicates that resident’s safety is paramount. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 21 Newly appointed staff are expected to complete the LDAF (Learning Disability Award Framework) to provide them with an understanding of the needs of people with learning difficulties. It was determined that 78 of care staff have successfully completed NVQ level 2 training, five of those also have level 3 and one has enrolled to undertake the course. The home has a rolling programme for staff training in Health and Safety, Moving and Handling, Food Hygiene, Autism, Epilepsy, Funeral Awareness, Equality and Diversity and all but one have Infection Control and the training has been arranged for the staff member. First Aid has been booked for half of the staff to attend. Staff receive training to carry out their roles and specific training to meet individuals needs. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager posses the skills to oversee the day to day management of the home. The quality assurance programme needs to be further developed to evidence that sustained improvements are an ongoing process. Arrangements in respect of health and safety are robust and prevents residents from incurring injuries. EVIDENCE: The registered manager is experienced and is keen to make continuing improvements for the benefit of residents. She displayed a transparent approach to residents and staff and viewed the inspection as a positive process. She is supported by the previous manager who still works part time and three senior carers. Staff spoken with reported the good support received from the manager and that she is approachable and willing to listen to Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 23 suggestions regarding changes. Although the manager is not part of the care staff team she advised of her willingness to work along side carers when necessary. Each carer has been delegated a specific role for them to complete and have ownership of. This promotes staff awareness of importance in assisting with the day to day running of the home. Audits of medications are carried out regularly by the manager. The home is currently sending out questionnaires to relatives and professionals and to date the responses have been positive. Staff are attempting to carry out satisfaction meetings with residents to ensure their involvement in the quality assurance process. A senior person within the organisation carries out unannounced monthly visits of the home and supplies the manager with a report of the findings. The home will need to carry out more audits and produce an annual report that includes the positive outcomes and shortfalls with an action plan and timescale for addressing them. The accident records are good and there is evidence of action taken where necessary. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting systems are regularly checked and the findings recorded to protect residents from harm in the event of an emergency situation. Regular fire drills are carried out and the names recorded of the staff who have attended to ensure that all staff are captured. The arrangements appear to protect residents and others from unnecessary risks of injury. Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 2 X X 3 x Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 25 No 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 YA22 Regulation 22(1) Requirement Timescale for action 15/06/07 2 YA39 The registered person must further develop the written complaints procedure to advise of the timescale for resolution of concerns raised. 31/07/07 24(1)(a)(b) The registered person must (2) further develop the quality assurance programme by carrying out further audits of the home and the services provided. Upon completion the results need to be amalgamated to other quality initiatives and a report developed that includes the good aspects and shortfalls and how and when they need to be addressed. 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 YA21 Good Practice Recommendations It is recommended that staff are provided with formal DS0000017002.V334965.R01.S.doc Version 5.2 Page 26 Westbourne Care training in care of the elderly to ensure that they possess the skills to care for those persons. 2. YA30 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.V334965.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westbourne Care DS0000017002.V334965.R01.S.doc Version 5.2 Page 28 - 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. 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