Inspection on 24/09/07 for Westbrook House

This inspection was carried out on 24th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Westbrook House 04/08/08

Westbrook House 11/01/07

Westbrook House 16/05/06

Westbrook House 13/09/05

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Westbrook House 150 Canterbury Road Westbrook Margate Kent CT9 5DD Lead Inspector Lisbeth Scoones Key Unannounced Inspection 09:15 24 September 2007 th X10015.doc Version 1.40 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 Westbrook House DS0000064161.V345304.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westbrook House Address 150 Canterbury Road Westbrook Margate Kent CT9 5DD 01843 254100 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) http/www.kent.gov.uk/SocialCare/children/fost ering/ Kent County Council Mrs Sarah Elizabeth Khamsoda Care Home 60 Category(ies) of Dementia - over 65 years of age (25), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15), Old age, not falling within any other category (30) Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 30 of occupied beds can be used at any one time for service users who are under the age of 65 years old but are over the age of 55 years. 11th January 2007 Date of last inspection Brief Description of the Service: The home is a large new purpose built care home, which is a joint project between the local authority (KCC) and the NHS PCT. The home has the facilities to provide intermediate care. Physiotherapists and occupational therapists are based in offices within the building. The home is laid out in four wings and has day centre facilities. The wings are used to provide separate areas of care according to the needs of the resident. These are intermediate care with nursing (2x 15), dementia (15) and mental health nursing (15). The home employs a team of registered nurses, health care assistants, team leaders and care workers. The ancillary & catering services are contracted. The home is situated close to local amenities and is on a main bus route. The grounds have two enclosed garden areas and a car park. The current scale of fees are: free for 6 weeks intermediate care then a scale of £303.25 to £367.82 for both dementia and intermediate care. Those residents residing at the Ogden unit have been assessed as requiring continuing care. The Welcome Pack clearly sets out which items and services are not included in the fees. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days on 24 and 25th September 2007. On 24th, two inspectors were involved with the inspection process, on 25th, one inspector. The inspection comprised discussions and meetings with the assistant manager, nursing sister and staff on the intermediate unit, assistant manager, senior team leader and staff in the dementia and mental health care units. A tour of the premises was carried out and documentation examined on all units. Documents related to care planning, medication administration, menus, staff rotas, complaints, staff files, audits and risk assessments. The inspection was further informed by an AQAA (annual quality assessment audit) completed by the registered manager prior to the visit. An improvement plan was received following the previous inspection. Comment cards completed by residents, relatives and staff were also received and comments made are incorporated in the report. The registered manager was not present at this inspection but joined the inspector for feedback on the second day. What the service does well: What has improved since the last inspection? The improvement plan submitted following the previous inspection identifies the action taken to meet the requirements. The appointment of senior staff in managerial roles with clear lines of accountability has ensured that the management structure has been strengthened. The Welcome Pack has been updated. An information brochure for the Intermediate Care service has been developed. The needs of prospective Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 6 residents the intermediate care unit intends to provide care for have been clarified. In Appleton unit, care plans have improved and relatives are involved in the writing of these. Activity sheets have been introduced demonstrating the type of activities residents have participated in. At the previous inspection it was recorded that residents need to be provided with stimulation through a programme of activities. At this inspection it was said that funding has been secured for an additional support worker. The additional hours would be used for the provision of activities. Staff with a responsibility for medication have attended update training sessions. Gardens have been improved Staff are provided with a structured training programme as evidenced on the training matrix. The recently appointed assistant manager in charge of the mental health unit is an adult protection and dementia care trainer. Quality assurance and additional audit monitoring tools has been devised to ensure that the home provides a good service. What they could do better: Residents would benefit from being cared for by a permanent staff team. This is being acted upon. In the intermediate care unit, there is still a need for additional equipment to be provided to assist with residents’ rehabilitation. There has been no change to items of furniture such as the dining tables and the soft armchairs identified previously as not appropriate. Residents’ care plans need to be further improved. More clarity should be provided in respect of “goals” in care plans in the intermediate care unit. The home needs to ensure that staff are provided with suitable tools to assist residents with making choices such as the choice of meals. Whilst laminated pictures of food items have now been provided, these should be further improved. An activities and orientation board should be provided in the Appleton unit. A training matrix is available. In due course every member of staff should have their own training and development assessment and profile. The staff Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 7 supervision programme is in place but not all staff receive such one–to-ones six times a year. Problems identified previously in respect of safe access to the home out of hours remain unresolved and must 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. The summary of this inspection report can be made available in other formats on request. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Before a resident is admitted to the home, their needs are assessed thus ensuring that these can be met. Residents assessed as requiring intermediate care are assisted and encouraged to maximise their independence and return home. However, the care plan must clearly identify individuals’ goals and how these are achieved. EVIDENCE: During the visit to the intermediate care unit, the inspectors spoke with residents, nursing, care and other staff. In relation to admission procedures, the occupational health assistant said that, following a recent restructure of the occupational and physiotherapy services, an agreed pathway for residents using the service has been introduced. The manager anticipates that, as a Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 10 result of this introduction, residents may be able to go home sooner with ongoing support from the same therapy team. See also standard 7 in relation to care plans and goal setting. The Welcome Pack has been updated. An information brochure for the Intermediate Care service has been developed. Clarification has been provided about the ‘type’ of prospective resident the intermediate care unit intends to provide care for. For residents admitted to the dementia care unit, a senior member of staff would carry out a pre-admission assessment. In respect of residents admitted for intermediate care, it was said that the home cannot always carry out such an assessment. However, a copy of the appropriate professionals assessment would be obtained. A screening tool has been introduced as part of the referral/admission process. The staff team in the intermediate care unit comprises care and nursing staff, and a team of therapists (occupational and physiotherapists), some of whom are employed by Social Services and others by the PCT. Weekly multidisciplinary meetings are held. At the previous inspection it was reported that there was a lack of clarity regarding the responsibility for writing residents’ assessments and rehabilitation plans. At this inspection it was noted that input from the physiotherapy team now informs the residents’ care plan. However, in respect of input from the occupational health team, although assessments were present in residents’ files, these had not informed the care plan. Similarly identified at the previous inspection, there is a lack of clarity re recording residents’ individual rehabilitation goals and whether these have been achieved. This issue was discussed with the nursing sister. The registered manager reported that, in relation to intermediate care, following a recent survey, 95 of residents discharged from Westbrook House achieved a ‘Sustained Discharge’ status. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst improved, care plans still require further attention to ensure that staff have sufficient information to meet the residents’ needs. Intermediate goals are not clearly identified in the care plan. Residents can feel confident that their health care needs will be met. Medications practices have improved but care plans in the intermediate unit should reflect that residents are supported or encouraged to manage their own medication. Residents are treated with dignity and respect. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans in the intermediate care unit contained adequate information for staff to carry out the care. However see comment in standard 6 regarding integrated input from the occupational health team. Staff must ensure that all sections are completed, signed and dated. Care plans examined in the dementia care units had improved. These now contain useful information for staff as how to deal with challenging behaviour. Residents’ relatives had signed the care plan. The assistant manager showed the inspector a template as to how the care plans are to be further improved. Residents have access to the GP of their choice or a visiting medical officer (VMO). Psychiatric and psychologist input is available to the residents in the dementia and mental health care units. Since the previous inspection all staff with a responsibility for medication have had additional training. Medication records were examined in the intermediate care unit. These had been well maintained. Pain charts were used to good effect. A recommendation was made for an “as required” protocol to be devised, which should include the use of codes for non-administration. The sister in the intermediate care unit is a nurse prescriber. At the previous inspection it was recorded that none of the residents in the intermediate unit administered their own medication. A this inspection it was recommended that, where residents have been assessed as able, records show that residents are encouraged and supported to self-medicate. A review of the self medicating assessment form should be undertaken to include arrangements for safe storage and responsibility for re ordering and periodic checks to ensure medicines are being taken correctly, the terminology used (patients) should also be reviewed. It was observed throughout the inspection that staff interacted with the residents in a dignified and respectful manner. In respect of dignity, it is recommended that all items of personal clothing be labelled. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents in the intermediate care unit are provided with some activities. In the dementia care unit, good facilities have been made available but these could be further improved. Excellent and structured person-centred activities are provided in the mental health unit. Residents are encouraged to maintain close links with their relatives and friends. Additional measures could be introduced to ensure that residents have control over their lives. Residents are provided with a good choice of wholesome, appetising meals. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 14 EVIDENCE: At this inspection the manager advised that funding has been secured for an additional care worker. It is intended that these additional hours be used for the provision of structured activities for the residents. During the morning of this inspection, residents were taking part in an exercise class carried out by a member of the occupational therapy team. Staff from the intermediate care units said activities in the afternoons are usually held on one of the units with residents being asked to move across to that unit to participate. Staff said residents are often reluctant to leave their own units and may benefit from activities being run on both units. In the Appleton wing (dementia), staff assisted the residents with puzzles and drawing. Since the previous inspection, activities sheets have been introduced demonstrating residents’ participation. A Life history has been obtained for each resident. Such information provides the staff with knowledge of residents’ previous life experience and interests. The assistant manager said that the concept of ‘memory boxes’ is being introduced. A relative said that he had provided such a box. The inspector spent some time with the residents and staff in the Ogden unit. A “Good morning, how are you” session took place followed by an activity whereby residents were encouraged to use musical instruments. Assisted by specialist and home staff, all residents participated according to their ability. Residents are provided with other leisure activities. A resident said that she had made cakes the previous day. A member of staff commented, “The transition team have been a great help with finding new ways of interacting with clients.” The assistant manager of the Ogden unit said that it is her intention to provide similar activities for the residents in the Appleton unit. Other plans for improvement were discussed. Two relatives commented that OT input in the unit would be helpful for the more active residents. The manager’s AQAA records that “funding is being sought for regular OT sessional support within the dementia services.” Relatives and staff commented on the positive contribution the recently appointed assistant manager had already made. Staff said they felt very supported and had benefited from the training. Residents from Ogden and Appleton have access to a sensory room and safe gardens. A resident said that he had been involved in potting up plants. It is evident that staff welcome visitors and relatives and involve them in residents’ care. In relation to safe access to the home out of hours, see standards 19 and 38. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 15 Residents and relatives spoken with praised the food. “It is excellent”. A relative was delighted that his wife had put on weight. A varied and nutritious menu is available as evidenced on menus seen and meals plated. However, staff must ensure that menus on display are correct. The use of additional visual aids to assist residents with their choice of meals was discussed. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are taken seriously, investigated and acted upon. Residents are protected from abuse. EVIDENCE: From conversations with residents and relatives it is evident that they know the route to take when there is an issue of concern. A complaint file perused evidenced that complaints are taken seriously and acted upon in a timely manner. The CSCI has received no complaints since the previous inspection. The home’s complaint procedure is incorporated in the Welcome Pack. The home has adult protection procedures, which are followed appropriately. The training matrix identifies that all staff have or are soon to be provided with adult protection training. The assistant manager in charge of the Ogden unit is an adult protection trainer. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a modern, spacious, well-maintained, purpose built care home. A security issue must be addressed. Some furniture is not appropriate for the needs & rehabilitation of the service users. Residents benefit from living in a clean and hygienic environment. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is a purpose built care home with a maintenance contract in place to ensure the building is maintained to its original standard. It provides a spacious, clean and modern environment. Since some framed artwork has been hung on the walls, the home has a more homely feel although this could be further improved. Gardens are available for all residents: for those residents residing on the ground floor these are secured. Improvements have been made to the security of the entry/exit of Appleton unit, which is to be extended to the Ogden unit. At previous inspections, it was reported that access to the building outside office hours continues to be problematic and relies on care staff leaving their work areas to allow visitors into the building. On comment cards completed by relatives, this issue was mentioned several times as a concern. Whilst a formal request for action has been submitted, the situation has not yet been resolved. See also standard 38. At the previous inspection it was identified that some of the furniture (low chairs and dining tables too low for wheelchair users) in the intermediate care units are not suitable. This issue was again discussed with the registered manager and occupational health assistant. At the previous inspection it was reported that there was a need for additional rehabilitation equipment. At this inspection it was reported that some additional equipment has now been made available All bedrooms have en-suite facilities including assisted walk-in showers. Additional assisted bathrooms are available. For those admitted for rehabilitation there are additional facilities proved; assisted kitchens and bathrooms. Residents from the intermediate care unit are not able to access the gardens easily unless they are able to manage stairs, otherwise they rely on staff to take them downstairs in the lift and through the building, to access the garden. The home provides a clean environment with good infection control systems. In a sluice room the air exchange vent was out of order. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by adequate numbers of staff on duty. However, the home continues to rely on agency staff. Residents are protected by the home’s recruitment policy and procedures. Permanent staff are provided with good training opportunities. EVIDENCE: Whilst some new staff have been recruited, the home continues to rely on significant numbers of agency staff. At this inspection it was reported that a recent recruitment drive had been successful and that both nursing and care staff are soon to join the staff. In conversation with staff they discussed the need for a full complement of staff. It was felt that only then good team working could be achieved. Several relatives said that agency staff don’t know the residents as well as regular staff. Staff spoken with said that relationships between staff employed by KCC and staff employed by the PCT continue to improve, and resolution of issues such as different pay scales and job descriptions and shift start times would Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 20 improve working relationships. A relative in the Appleton unit said that staffing levels could be improved especially around meal times. A training matrix is now in place evidencing training carried out and planned. Staff are to receive training in issues of Equality and Diversity. In due course, it is recommended that each member of staff has an individual training and development profile. The devising of such a profile could be linked to supervision. See also standard 36. The assistant manager in charge of the Ogden unit is a training facilitator for dementia care and adult protection and a moving and handling coordinator. The manager reported that 7 members of staff are to undertake their NVQ training in the next 12 months. Once completed, the ratio of trained staff would be 57 . A sample of staff files was examined and this evidenced that sound recruitment procedures are followed. It was reported that all existing staff are in the process of undertaking induction programme according to “Core Induction Standards.” All new staff would be provided with such training. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Since the recruitment of senior staff with delegated roles and responsibilities, the management of the home has improved. The home is run in the best interests of the residents. Residents’ financial interests are safeguarded. Staff are supervised but the process needs to be strengthened. Records are kept with due regard for confidentiality. The health, safety and welfare of residents and staff are promoted but must be further improved. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has the skills and knowledge required for running the home. Since the previous inspection, key management posts have been filled: an assistant manager (RMN) in charge of the Ogden unit and nursing sister for the intermediate care units. The inspectors met with both members of staff and discussed their roles and ambitions for the future. Additional nursing and health care staff have been appointed. See also standard 27. Staff spoken with praised the assistant managers and nursing sister for their support and guidance. A member of staff said,” the relationship with my manager is excellent. She is extremely supportive in work and personal matters.” The manager said that communication between the different teams within the home and the different employment groups (PCT & NHS) has improved. Staff said communication and implementation of new practices could be improved as often new initiatives were lost perhaps due to the high number of agency staff used and or poor communication. On the intermediate care units communication at the “handover” could be improved as the differing start and finish times of care staff means that not all staff receive handover. Staff also said that during the day care staff hand over to each other and do not always receive a hand over from the trained staff. The registered manager said that quality assurance systems have improved and new monitoring tools introduced. In the dementia care and mental health care units monthly carers meetings are well attended. Care plans and medication audits are carried out. Residents are asked for their views through quality surveys. Monthly staff meetings are held and quarterly staff surveys introduced. Clinical governance meetings are held jointly with another care home to develop integrated procedures. The inspector was presented with a monthly audit tool, which would enable the registered manager to give an overview of the service as a whole. A new set of policies is due to be introduced in the near future. Following this introduction, it is anticipated that a yearly system of review of policies and local procedures would be implemented. From information provided before the inspection, it is ascertained that residents’ monies may be handled through a none-interest making bank account. None of the staff are appointees for service users and records are kept. Staff are provided with supervision but for some staff this has been delayed. With the appointment of senior staff it is expected that regular staff supervision will now take place. Nurses are provided with clinical supervision. Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 23 Since the previous inspection, lockable boxes have been provided to safely store confidential records. Whilst every unit has a duty office, these offices are away from the residents’ area. The difficulties of this situation were discussed. From information supplied by the registered manager, it is ascertained that all maintenance and certificates for the servicing of equipment and services are up to date. The Fire logbook recorded that safety checks were conducted regularly. All staff are provided with statutory training including moving and handling, first aid and infection control. See also standard 19 in respect of out of hours access to the home. Westbrook House DS0000064161.V345304.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x 2 x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 2 3 2 Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 25 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 OP6 Regulation 15 Requirement That residents receiving intermediate care have clearly defined goals identified. That records provide evidence of these being evaluated to determine if these goals have been achieved OP7 2 3 OP36 OP19 OP38 18 (2) 23 (2) (a) That care plans identify all care needs and intervention required That all staff have supervision at appropriate intervals That the security of the building and the door entry system be reviewed for when the receptionist is off duty. (Nursing and care staff time must not be used for this purpose. Previous timescales not met 4 OP22 14 (1) (a) 16 (2) c That the home provides appropriate equipment to enable residents to complete their rehabilitation programme 31/10/07 31/10/07 31/10/07 Timescale for action 31/10/07 Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 26 This is a previous requirement 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 OP4 Good Practice Recommendations That documents and information relevant to the residents be produced in appropriate formats, such as pictorial menus etc. That a protocol for “as required” medication be devised That records evidence that residents receiving intermediate are encouraged and supported to selfmedicate their own medicines when assessed as capable 3 4 5 OP10 OP12 OP30 That all personal clothing is labelled That the range of activities provided is extended That all staff have an individual training and development assessment and profile 2 OP9 Westbrook House DS0000064161.V345304.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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